Provider Demographics
NPI:1700898822
Name:POCATELLO CHILDREN & ADOLESCENT CLINIC
Entity Type:Organization
Organization Name:POCATELLO CHILDREN & ADOLESCENT CLINIC
Other - Org Name:POCATELLO CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-239-3400
Mailing Address - Street 1:1151 HOSPITAL WAY BLDG F
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-232-1443
Mailing Address - Fax:208-239-3434
Practice Address - Street 1:1151 HOSPITAL WAY BLDG F
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-232-1443
Practice Address - Fax:208-239-3434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POCATELLO CHILDREN'S CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-13
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002601400Medicaid