Healthcare Provider Details

I. General information

NPI: 1710374301
Provider Name (Legal Business Name): THE WALKER CENTER FOR ALCOHOLISM AND DRUG ABUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 11TH AVE E
GOODING ID
83330-5368
US

IV. Provider business mailing address

605 11TH AVE E
GOODING ID
83330-5368
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-8461
  • Fax: 208-934-5437
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1136-02
License Number StateHI

VIII. Authorized Official

Name: ELIZABETH AMY KAST
Title or Position: COMMUNITY NETWORK MANAGER
Credential:
Phone: 208-934-8461