1437783529 NPI number — TELEMENTAL HEALTH LINK LLC

Table of content: (NPI 1437783529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437783529 NPI number — TELEMENTAL HEALTH LINK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TELEMENTAL HEALTH LINK LLC
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:
6
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:
1437783529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4055 E BLUEBERRY ST
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:
83642-8261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-600-2060
Provider Business Mailing Address Fax Number:
208-647-5008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4055 E BLUEBERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-775-7418
Provider Business Practice Location Address Fax Number:
208-647-5008
Provider Enumeration Date:
02/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DERIVAS
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
AO
Authorized Official Telephone Number:
208-775-7418

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 396453OSMIND . This is a "CHANGE HEALTHCARE MASTER BILLING ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 58322 . This is a "NURSING LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 58322 . This is a "NEW MEXICO APRN CNP LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 020837 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13961493 . This is a "CAQH ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64266 . This is a "NURSING LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 03962 . This is a "NURSING LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1529234 . This is a "NCSBN ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0364158 . This is a "ANCC CERTIFICATION NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 363LP0808X . This is a "TAXONOMIES: NURSE PRACTITIONER PSYCH MENTAL HEALTH" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: P69441 . This is a "UPIN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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