Provider Demographics
NPI:1942308986
Name:IDAHO FALLS RECOVERY CENTER
Entity Type:Organization
Organization Name:IDAHO FALLS RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSIST. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHURTLIFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-5285
Mailing Address - Street 1:1957 E 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-529-5285
Mailing Address - Fax:208-529-5287
Practice Address - Street 1:1957 E 17TH STREET
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-529-5285
Practice Address - Fax:208-529-5287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00638OtherBLUE CROSS
ID00638OtherBLUE CROSS