Healthcare Provider Details

I. General information

NPI: 1265635205
Provider Name (Legal Business Name): BLACKFOOT MEDICAL CLINIC MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 PARKWAY DR
BLACKFOOT ID
83221-1667
US

IV. Provider business mailing address

1441 PARKWAY DR
BLACKFOOT ID
83221-1667
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-2600
  • Fax:
Mailing address:
  • Phone: 208-785-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: BETTY MILLER
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 208-785-2600