Provider Demographics
NPI:1356577019
Name:GRAND TETON SERVICE GROUP
Entity type:Organization
Organization Name:GRAND TETON SERVICE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS/PSYCHOLOGY
Authorized Official - Phone:208-528-7443
Mailing Address - Street 1:PO BOX 50457
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-0457
Mailing Address - Country:US
Mailing Address - Phone:208-528-7443
Mailing Address - Fax:208-528-7321
Practice Address - Street 1:329 PARK AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3610
Practice Address - Country:US
Practice Address - Phone:208-528-7443
Practice Address - Fax:208-528-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRHA-313320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0026966Medicaid