Healthcare Provider Details

I. General information

NPI: 1922340124
Provider Name (Legal Business Name): HUMAN SUPPORTS OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4477 W EMERALD ST STE C-100
BOISE ID
83706-2000
US

IV. Provider business mailing address

PO BOX 820
CALDWELL ID
83606-0820
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-8389
  • Fax: 208-454-8404
Mailing address:
  • Phone: 208-454-8389
  • Fax: 208-454-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALITA RUBY
Title or Position: ADMINISTRATEIVE SERVICES MANAGER
Credential:
Phone: 208-454-8389