Provider Demographics
NPI:1174629976
Name:PORTNEUF VALLEY FAMILY CENTER
Entity type:Organization
Organization Name:PORTNEUF VALLEY FAMILY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DE WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-7832
Mailing Address - Street 1:PO BOX 4908
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4908
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:844-946-0909
Practice Address - Street 1:444 HOSPITAL WAY STE 477
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2744
Practice Address - Country:US
Practice Address - Phone:208-233-7832
Practice Address - Fax:208-233-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807338300Medicaid
ID807319500Medicaid