1407069438 NPI number — INCLUSION NORTH, INC

Table of content: (NPI 1407069438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407069438 NPI number — INCLUSION NORTH, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INCLUSION NORTH, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407069438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
880 E FRANKLIN RD
Provider Second Line Business Mailing Address:
#303
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-6099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-888-1758
Provider Business Mailing Address Fax Number:
208-895-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-8041
Provider Business Practice Location Address Fax Number:
208-882-4079
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHANEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPTROLLER
Authorized Official Telephone Number:
208-888-1758

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8052062 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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