1396907861 NPI number — ALL DEVELOPMENTAL DISABILITY SERVICES

Table of content: (NPI 1396907861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396907861 NPI number — ALL DEVELOPMENTAL DISABILITY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALL DEVELOPMENTAL DISABILITY SERVICES
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:
1396907861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2717 S KIMBALL 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:
83605-5623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-465-5114
Provider Business Mailing Address Fax Number:
208-465-5198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 S VISTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-424-3160
Provider Business Practice Location Address Fax Number:
208-433-9794
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MITTON
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PROGRAM ADMINISTRATOR
Authorized Official Telephone Number:
208-465-5114

Provider Taxonomy Codes

  • Taxonomy code: 261QD1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 808063101 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808077800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808317200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808065600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808063100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808077801 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808065601 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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