Provider Demographics
NPI:1144546649
Name:GERICARE OF IDAHO, LLC
Entity type:Organization
Organization Name:GERICARE OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-830-6775
Mailing Address - Street 1:5310 WARD ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-1829
Mailing Address - Country:US
Mailing Address - Phone:303-278-7418
Mailing Address - Fax:888-341-5050
Practice Address - Street 1:5442 S FARMHOUSE PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-9016
Practice Address - Country:US
Practice Address - Phone:208-830-6775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-297771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS 10041OtherSTATE LICENSE
IDLCSW-29777OtherSTATE LICENSE