NPIMap

Organization Active NPI

South Park, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Pocatello, ID
National Provider Identifier
1295954139
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
00259790 Issued in ID
Legal business name
SOUTH PARK, INC.
Practice address
2369 Rulon Ave
Pocatello, ID 83201-1881
Phone
(208) 237-5538
NPI assigned
Apr 25, 2007
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 00259790 ID Primary

Addresses

Primary practice location

2369 Rulon Ave
Pocatello, ID 83201-1881

Mailing address

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

Other names 1

  • Rulon House Group Home Other name

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.

NPI Registry JSON

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

{
    "created_epoch": "1177459200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1295954139",
    "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": "2369 RULON AVE",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832011881",
            "telephone_number": "208-237-5538"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH PARK, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-25",
        "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": "00259790",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rulon House Group Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Pocatello, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.