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NPI Code Detail

MEDICARE: PATHWAYS OF IDAHO, LLC

MEDICARE: PATHWAYS OF IDAHO, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)
2251S00000XCommunity/Behavioral Health Agency

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
120004720OTHERIDMEDICARE PTAN

General Provider Information

NPI Number : 1326466988
Entity Type Code : Organization
Provider Name (Legal Business Name) : PATHWAYS OF IDAHO, LLC
Provider Business Mailing Address
First Line : 545 N BENJAMIN LN STE 185
Second Line :
City : BOISE
State : ID
Zip : 83704-9625
Country : US
Telephone Number : 208-322-1026
Fax Number : 208-322-1029
Provider Business Practice Location Address
First Line : 545 N BENJAMIN LN STE 185
Second Line :
City : BOISE
State : ID
Zip : 83704-9625
Country : US
Telephone Number : 208-322-1026
Fax Number : 208-322-1029
Authorized Official
Title or Position : IDAHO STATE DIRECTOR
Name : MR. RYAN JONES
Credential :
Telephone Number : 208-322-1026
Provider Enumeration Date : 04/01/2014
Last Update Date : 06/20/2024

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Directions to “PATHWAYS OF IDAHO, LLC ” Practice Location

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