Provider Demographics
NPI:1952668568
Name:POCATELLO PA SERVICE LLC
Entity Type:Organization
Organization Name:POCATELLO PA SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:BOE
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-241-0876
Mailing Address - Street 1:2310 SATTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-7905
Mailing Address - Country:US
Mailing Address - Phone:208-241-0876
Mailing Address - Fax:
Practice Address - Street 1:333 N 18TH AVE STE D2
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-232-6490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-272332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies