Provider Demographics
NPI:1952674988
Name:MY BROTHER'S KEEPER MBK
Entity Type:Organization
Organization Name:MY BROTHER'S KEEPER MBK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:JOLEEN
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPRP
Authorized Official - Phone:208-339-4356
Mailing Address - Street 1:704 S COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1861
Mailing Address - Country:US
Mailing Address - Phone:208-339-4356
Mailing Address - Fax:
Practice Address - Street 1:704 S COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1861
Practice Address - Country:US
Practice Address - Phone:208-339-4356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 261QM0801X, 261QM0850X
ID251S00000X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health