Healthcare Provider Details

I. General information

NPI: 1831183888
Provider Name (Legal Business Name): DIVERSIFIED SOCIAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 N GOVT WAY SUITE B
DALTON GARDENS ID
83815-8702
US

IV. Provider business mailing address

6640 N GOVT WAY SUITE B
DALTON GARDENS ID
83815-8702
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-9890
  • Fax: 208-762-9892
Mailing address:
  • Phone: 208-762-9890
  • Fax: 208-762-9892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KRISTINA NICHOLAS
Title or Position: PROGRAM MANAGER/PRESIDENT
Credential: LSW
Phone: 208-762-9890