NPIMap

Organization Active NPI

South Park, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Pocatello, ID
National Provider Identifier
1205056538
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
00259810 Issued in ID
Legal business name
SOUTH PARK, INC.
Practice address
1722 Church Hill Downs
Pocatello, ID 83201
Phone
(208) 237-2010
NPI assigned
Apr 27, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Russell C McCoy, M.A.ED
Title
Executive Director
Phone
(208) 233-6833

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 00259810 ID Primary

Addresses

Primary practice location

1722 Church Hill Downs
Pocatello, ID 83201

Mailing address

415 S Arthur Ave
Pocatello, ID 83204-3303
Phone (208) 233-6833

Other names 1

  • Church Hill Downs Group Home Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1205056538. Details of each certification follow.

  • CCN 13G020 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 13G020

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
Olympus Heights Group Home
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Mar 16, 1987
Last certification
May 22, 2025
Beds
8
Ownership / control type
Private (non-profit)
Facility address
1722 Church Hill Downs
Pocatello, ID 83201

National Provider Directory

National Provider Directory
Tax ID family
Developmental Options8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177632000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1205056538",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "415 S ARTHUR AVE",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832043303",
            "telephone_number": "208-233-6833",
            "fax_number": "208-233-6842"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1722 CHURCH HILL DOWNS",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "83201",
            "telephone_number": "208-237-2010"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH PARK, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-27",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MCCOY",
        "authorized_official_first_name": "RUSSELL",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "208-233-6833",
        "authorized_official_credential": "M.A.ED"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "ID",
            "license": "00259810",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Church Hill Downs Group Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Pocatello, ID

Sources for this page

Verify at the official NPI Registry.