Provider Demographics
NPI:1548697006
Name:ST. LUKE'S ELKS CHILDRENS REHAB
Entity type:Organization
Organization Name:ST. LUKE'S ELKS CHILDRENS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE AND RISK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-489-4761
Mailing Address - Street 1:405 W MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 W MYRTLE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7658
Practice Address - Country:US
Practice Address - Phone:208-489-5880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2340283XC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283XC2000XHospitalsRehabilitation HospitalChildren