1780879700 NPI number — SOUTHEASTERN IDAHO DEVELOPMENTAL CENTER, INC.

Table of content: (NPI 1780879700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780879700 NPI number — SOUTHEASTERN IDAHO DEVELOPMENTAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN IDAHO DEVELOPMENTAL CENTER, INC.
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:
1780879700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 701
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACKFOOT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83221-0701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-782-1301
Provider Business Mailing Address Fax Number:
208-782-3627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
765 W JUDICIAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKFOOT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83221-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-1301
Provider Business Practice Location Address Fax Number:
208-782-3627
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOY
Authorized Official First Name:
JIM
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OWNER DIRECTOR
Authorized Official Telephone Number:
208-782-1301

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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