MEDICARE: POWDER BASIN ASSOCIATES INC

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1679596068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWDER BASIN ASSOCIATES INC

Provider Business Mailing Address
First Line	:	7905 N MEADOWLARK WAY
Second Line	:	STE C
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-5041
Country	:	US
Telephone Number	:	208-762-3979
Fax Number	:	208-762-4419

Provider Business Practice Location Address
First Line	:	7905 N MEADOWLARK WAY
Second Line	:	STE C
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-5041
Country	:	US
Telephone Number	:	208-762-3979
Fax Number	:	208-762-4419

Authorized Official
Title or Position	:	OWNER
Name	:	LYNN MOORE
Credential	:
Telephone Number	:	208-676-0472

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	10/03/2007

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