1952474777 NPI number — IDAHO STATE UNIVERSITY

Table of content: (NPI 1952474777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952474777 NPI number — IDAHO STATE UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO STATE UNIVERSITY
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:
IDAHO STATE UNIVERSITY SPEECH & HEARING CLINIC
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:
1952474777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 S 8TH AVE STOP 8116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83209-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-282-3495
Provider Business Mailing Address Fax Number:
208-282-4571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
BLDG #68
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-3495
Provider Business Practice Location Address Fax Number:
208-282-4571
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROCK
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CLINICS DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
208-373-1743

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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