Organization
SEQUEL TSI OF IDAHO, LLC
Active
Other names
Mountain Home RTC
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHN STUPAK (PRESIDENT)
(267) 419-8913
Entity
Organization
Contact information
Practice address
2850 INDUSTRIAL WAY, MOUNTAIN HOME, ID 83647-3960
(208) 587-2679
(208) 587-2875
Mailing address
2850 INDUSTRIAL WAY, MOUNTAIN HOME, ID 83647-3960
(208) 587-2679
(208) 587-2875
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
—
—
Other
Enumeration date
12/30/2009
Last updated
12/30/2009
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