1710284047 NPI number — IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH

Table of content: (NPI 1710284047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710284047 NPI number — IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH
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:
1710284047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST MARIES
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83861-1847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-245-2541
Provider Business Mailing Address Fax Number:
208-245-7131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-1847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-2541
Provider Business Practice Location Address Fax Number:
208-245-7131
Provider Enumeration Date:
02/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
208-769-1406

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HW256 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010018348 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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