Healthcare Provider Details

I. General information

NPI: 1043556608
Provider Name (Legal Business Name): LATINO STAND UP IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 WOODRUFF PARK
IDAHO FALLS ID
83401-3330
US

IV. Provider business mailing address

1680 WOODRUFF PARK
IDAHO FALLS ID
83401-3330
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-6373
  • Fax: 208-552-2188
Mailing address:
  • Phone: 208-552-6373
  • Fax: 208-552-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. ROGER HORNE
Title or Position: OWNER
Credential:
Phone: 910-573-0861