1609902980 NPI number — REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER

Table of content: (NPI 1609902980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609902980 NPI number — REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER
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:
CHILD & YOUTH STUDY CENTER
Provider Other Organization Name Type Code:
3
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:
1609902980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
875 PERIMETER DRIVE
Provider Second Line Business Mailing Address:
MS 4061
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83844-4061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-885-3588
Provider Business Mailing Address Fax Number:
208-885-3536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 WEST SWEET AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-885-6191
Provider Business Practice Location Address Fax Number:
208-885-6188
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
GWEN
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
208-885-6191

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807220700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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