Healthcare Provider Details

I. General information

NPI: 1306182910
Provider Name (Legal Business Name): LATINO STAND UP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 E 17TH ST SUITE A
IDAHO FALLS ID
83404-6283
US

IV. Provider business mailing address

1420 E 17TH ST SUITE A
IDAHO FALLS ID
83404-6283
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-0711
  • Fax:
Mailing address:
  • Phone: 208-313-0711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ROMAN CRUZ
Title or Position: OWNER
Credential:
Phone: 208-313-0711