# SEQUEL TSI OF IDAHO, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Mountain Home RTC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073843868
- **Authorized official:** MR. JOHN STUPAK (PRESIDENT)
- **Authorized official phone:** (267) 419-8913

## Contact information

- **Practice address:** 2850 INDUSTRIAL WAY, MOUNTAIN HOME, ID 83647-3960
- **Practice address phone:** (208) 587-2679
- **Practice address fax:** (208) 587-2875
- **Mailing address:** 2850 INDUSTRIAL WAY, MOUNTAIN HOME, ID 83647-3960
- **Mailing address phone:** (208) 587-2679
- **Mailing address fax:** (208) 587-2875

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 12/30/2009
- **Last updated:** 12/30/2009