# GRAND TETON SERVICE GROUP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1548496201
- **Authorized official:** MRS. LISA BOWMAN MASTERS/PSYCHOLOGY (PROGRAM DIRECTOR)
- **Authorized official phone:** (208) 528-7443

## Contact information

- **Practice address:** 329 PARK AVE, IDAHO FALLS, ID 83402-3610
- **Practice address phone:** (208) 528-7443
- **Practice address fax:** (208) 528-7321
- **Mailing address:** PO BOX 50457, IDAHO FALLS, ID 83405-0457
- **Mailing address phone:** (208) 528-7443
- **Mailing address fax:** (208) 528-7321

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | RHA-313 | ID | Yes |

## Other

- **Enumeration date:** 06/08/2009
- **Last updated:** 06/08/2009