Organization
SOUTH PARK, INC.
Active
Other names
Developmental Options
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
415 S ARTHUR AVE, POCATELLO, ID 83204-3303
(208) 233-6833
(208) 233-6842
Mailing address
415 S ARTHUR AVE, POCATELLO, ID 83204-3303
(208) 233-6833
(208) 233-6842
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
ID
315P00000X
Intellectual Disabilities Intermediate Care Facility
15
ID
315P00000X
Intellectual Disabilities Intermediate Care Facility
20
ID
315P00000X
Intellectual Disabilities Intermediate Care Facility
43
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00259790
—
ID
05
—
00259800
—
ID
05
—
00259810
—
ID
Enumeration date
02/12/2007
Last updated
09/11/2025
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