Healthcare Provider Details

I. General information

NPI: 1346363561
Provider Name (Legal Business Name): ID DEPT OF HEALTH & WELFARE CSHP (HD5)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 OLD PENITENTIARY RD
BOISE ID
83712-8249
US

IV. Provider business mailing address

PO BOX 83720 4TH FLOOR
BOISE ID
83720-0036
US

V. Phone/Fax

Practice location:
  • Phone: 208-334-2235
  • Fax: 208-334-2382
Mailing address:
  • Phone: 208-334-4935
  • Fax: 208-332-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PAIGE FINCHER
Title or Position: ACTING PROGRAM MANAGER
Credential: BSW
Phone: 208-334-4935