1669775060 NPI number — ABUNDANCE BEHAVIORAL HEALTH SERVICES INC.

Table of content: (NPI 1669775060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669775060 NPI number — ABUNDANCE BEHAVIORAL HEALTH SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANCE BEHAVIORAL HEALTH SERVICES 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:
1669775060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 N 21ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83605-4371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-455-1222
Provider Business Mailing Address Fax Number:
208-455-2559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 N 21ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-455-1222
Provider Business Practice Location Address Fax Number:
208-455-2559
Provider Enumeration Date:
12/08/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEGGE
Authorized Official First Name:
MOLLY
Authorized Official Middle Name:
VIRGINIA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
208-455-1222

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1669795308 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891913125 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1659590727 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".