Organization
SOUTH PARK, INC.
Active
Other names
South Bannock Groupl Home
Organization subpart
No
Provider details
NPI number
Authorized official
RUSSELL C MCCOY M.A.ED (EXECUTIVE DIRECTOR)
(208) 233-6833
Entity
Organization
Contact information
Practice address
3875 BANNOCK HWY, POCATELLO, ID 83204-4405
(208) 233-6844
Mailing address
415 S ARTHUR AVE, POCATELLO, ID 83204-3303
(208) 233-6833
(208) 233-6842
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
00259800
ID
Other
Enumeration date
05/01/2007
Last updated
08/22/2020
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