Provider Demographics
NPI:1942616073
Name:ST LUKE'S ELKS CHILDRENS REHABILITATION
Entity Type:Organization
Organization Name:ST LUKE'S ELKS CHILDRENS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MERIDIAN SITE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAVITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-489-5099
Mailing Address - Street 1:3525 E LOUISE DR
Mailing Address - Street 2:SUITE 255
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6302
Mailing Address - Country:US
Mailing Address - Phone:208-489-5099
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR
Practice Address - Street 2:SUITE 255
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6302
Practice Address - Country:US
Practice Address - Phone:208-489-5099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-963261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation