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Organization
GRAND TETON SERVICE GROUP
Active
Organization
GRAND TETON SERVICE GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LISA BOWMAN MASTERS/PSYCHOLOGY (PROGRAM DIRECTOR)
(208) 528-7443
Entity
Organization
Contact information
Practice address
329 PARK AVE, IDAHO FALLS, ID 83402-3610
(208) 528-7443
(208) 528-7321
Mailing address
PO BOX 50457, IDAHO FALLS, ID 83405-0457
(208) 528-7443
(208) 528-7321
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
RHA-313
ID
Other
Enumeration date
06/08/2009
Last updated
06/08/2009
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