Provider Demographics
NPI:1982089678
Name:GLENNS FERRY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GLENNS FERRY HEALTH CENTER, INC.
Other - Org Name:DESERT SAGE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-696-7203
Mailing Address - Street 1:120 DESERT SAGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1038
Mailing Address - Country:US
Mailing Address - Phone:208-696-7203
Mailing Address - Fax:
Practice Address - Street 1:120 DESERT SAGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-1038
Practice Address - Country:US
Practice Address - Phone:208-696-7203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty