Organization
LIFE CHANGE ASSOCIATES, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DERIC V RAVSTEN DO (OWNER)
(208) 233-5433
Entity
Organization
Contact information
Practice address
1777 E CLARK ST, SUITE 330, POCATELLO, ID 83201-3357
(208) 233-5433
(877) 284-2783
Mailing address
1777 E CLARK ST, SUITE 330, POCATELLO, ID 83201-3357
(208) 233-5433
(877) 284-2783
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
ID
2084P0800X
Psychiatry Physician
Primary
—
ID
363A00000X
Physician Assistant
—
ID
Other
Enumeration date
07/07/2010
Last updated
11/23/2013
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