Healthcare Provider Details

I. General information

NPI: 1932248234
Provider Name (Legal Business Name): IDAHO DEPT OF HEALTH & WELFARE ITP REG. 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 IRONWOOD CT
COEUR D ALENE ID
83814-2628
US

IV. Provider business mailing address

2195 IRONWOOD CT
COEUR D ALENE ID
83814-2628
US

V. Phone/Fax

Practice location:
  • Phone: 208-769-1409
  • Fax: 208-769-1430
Mailing address:
  • Phone: 208-769-1409
  • Fax: 208-769-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateID

VIII. Authorized Official

Name: MS. MARY J JONES
Title or Position: PROGRAM MANAGER
Credential: B.U.S.
Phone: 208-334-5523