| Sanctuary Ntc | |
|
4737 S Afton Pl Suite A Chubbuck ID 83202-2317 | |
| (208) 417-0623 | |
| (208) 417-0641 |
| Full Name | Sanctuary Ntc |
|---|---|
| Speciality | Clinic/Center |
| Location | 4737 S Afton Pl, Chubbuck, Idaho |
| Authorized Official Name and Position | Tyrone Shuman (OWNER) |
| Authorized Official Contact | 2084170623 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Sanctuary Ntc Po Box 2431 Pocatello ID 83206-2431 Ph: (208) 417-0623 | Sanctuary Ntc 4737 S Afton Pl Suite A Chubbuck ID 83202-2317 Ph: (208) 417-0623 |
| NPI Number | 1649607250 |
|---|---|
| Provider Enumeration Date | 09/27/2013 |
| Last Update Date | 09/11/2023 |
| Certification Date | 09/11/2023 |
| Medicare PECOS PAC ID | 9739319807 |
|---|---|
| Medicare Enrollment ID | O20140529002400 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1649607250 | NPI | - | NPPES |
| Provider Name | Sandra L Vollmer |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1043510613 PECOS PAC ID: 7416177258 Enrollment ID: I20140930001126 |
| Provider Name | Daniel L Traughber |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1386944411 PECOS PAC ID: 9234352741 Enrollment ID: I20141104002644 |
| Provider Name | Russell Vollmer |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1962813253 PECOS PAC ID: 4587888938 Enrollment ID: I20180117001216 |
| Provider Name | Jason C Schickedanz |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1295041630 PECOS PAC ID: 5799112249 Enrollment ID: I20200224001604 |
| Provider Name | Joseph Daniel Lenihan |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1760893838 PECOS PAC ID: 4486080769 Enrollment ID: I20200228000532 |
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