Healthcare Provider Details

I. General information

NPI: 1700913340
Provider Name (Legal Business Name): IDAHO DHWBH3 CALDAMHCLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 FRANKLIN RD
CALDWELL ID
83605-6932
US

IV. Provider business mailing address

3402 FRANKLIN RD
CALDWELL ID
83605-6932
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-0092
  • Fax: 208-454-7714
Mailing address:
  • Phone: 208-459-0092
  • Fax: 208-454-7714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TODD L HURT
Title or Position: FIELD OPERATIONS MANAGER
Credential: M.S.
Phone: 208-455-7057