Provider Demographics
NPI:1184433005
Name:GARNET STATE ENTERPRISES LLC
Entity type:Organization
Organization Name:GARNET STATE ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:208-518-9927
Mailing Address - Street 1:2481 HALLEBERRY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8339
Mailing Address - Country:US
Mailing Address - Phone:208-518-9927
Mailing Address - Fax:
Practice Address - Street 1:2481 HALLEBERRY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8339
Practice Address - Country:US
Practice Address - Phone:208-518-9927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty