Provider Demographics
NPI:1023667524
Name:GEM STATE DEVELOPMENTAL CENTER LLC
Entity type:Organization
Organization Name:GEM STATE DEVELOPMENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-888-5566
Mailing Address - Street 1:818 NW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3724
Mailing Address - Country:US
Mailing Address - Phone:208-888-5566
Mailing Address - Fax:208-888-5578
Practice Address - Street 1:818 NW 15TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3724
Practice Address - Country:US
Practice Address - Phone:208-888-5566
Practice Address - Fax:208-888-5578
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYRINGA SOCIAL SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty