Provider Demographics
NPI:1447811948
Name:B&G INTERNATIONAL, LLC
Entity type:Organization
Organization Name:B&G INTERNATIONAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:M
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-254-0133
Mailing Address - Street 1:1110 YELLOWSTONE AVE # 178
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4312
Mailing Address - Country:US
Mailing Address - Phone:208-254-0133
Mailing Address - Fax:
Practice Address - Street 1:15149 W LACEY RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-5044
Practice Address - Country:US
Practice Address - Phone:208-254-0133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty