1407998594 NPI number — COUNTY OF CARIBOU IND SCHOOL DIST 149

Table of content: (NPI 1407998594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407998594 NPI number — COUNTY OF CARIBOU IND SCHOOL DIST 149

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF CARIBOU IND SCHOOL DIST 149
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:
1407998594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E FAIRVIEW AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-922-3093
Provider Business Mailing Address Fax Number:
208-922-9351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
322 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANCROFT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-648-7848
Provider Business Practice Location Address Fax Number:
208-648-7895
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEVESQUE
Authorized Official First Name:
TODD
Authorized Official Middle Name:
KENNETH
Authorized Official Title or Position:
SYSTEMS MANAGER
Authorized Official Telephone Number:
208-922-3093

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , 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: 805634400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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