NPIMap

Organization Active NPI

Grand Teton Service Group

  • Intellectual and/or Developmental Disabilities Residential Treatment Facility
  • Idaho Falls, ID
National Provider Identifier
1356577019
Registry record updated Jun 8, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Residential Treatment FacilityTaxonomy code 320600000X
License
RHA-313 Issued in ID
Legal business name
GRAND TETON SERVICE GROUP
Practice address
329 Park Ave
Idaho Falls, ID 83402-3610
Phone
(208) 528-7443
Fax
(208) 528-7321
NPI assigned
Jun 8, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 8, 2009

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

Authorized official

Name
Ms. Lisa Bowman, MASTERS/PSYCHOLOGY
Title
Program Director
Phone
(208) 528-7443

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual and/or Developmental Disabilities Residential Treatment Facility 320600000X RHA-313 ID Primary

Addresses

Primary practice location

329 Park Ave
Idaho Falls, ID 83402-3610

Mailing address

PO Box 50457
Idaho Falls, ID 83405-0457
Phone (208) 528-7443

Other identifiers 1

IdentifierTypeStateIssuer
0026966MedicaidID

National Provider Directory

National Provider Directory
Tax ID family
Grand Teton Service Group3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

NPI Registry JSON

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

{
    "created_epoch": "1244419200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1244419200000",
    "number": "1356577019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 50457",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834050457",
            "telephone_number": "208-528-7443",
            "fax_number": "208-528-7321"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "329 PARK AVE",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834023610",
            "telephone_number": "208-528-7443",
            "fax_number": "208-528-7321"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND TETON SERVICE GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-06-08",
        "last_updated": "2009-06-08",
        "status": "A",
        "authorized_official_last_name": "BOWMAN",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "PROGRAM DIRECTOR",
        "authorized_official_telephone_number": "208-528-7443",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "MASTERS/PSYCHOLOGY"
    },
    "taxonomies": [
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "ID",
            "license": "RHA-313",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0026966",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 8, 2009; 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.