Healthcare Provider Details

I. General information

NPI: 1376935494
Provider Name (Legal Business Name): APEX ADVENTURE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 E 1750 S
GOODING ID
83330-5177
US

IV. Provider business mailing address

1832 E 1750 S
GOODING ID
83330-5177
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-4444
  • Fax: 208-934-5171
Mailing address:
  • Phone: 208-934-4444
  • Fax: 208-934-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number38122
License Number StateID

VIII. Authorized Official

Name: MS. KATHY REX
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-308-3163