Healthcare Provider Details

I. General information

NPI: 1447557772
Provider Name (Legal Business Name): IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 WILDCAT WAY
KELLOGG ID
83837-2261
US

IV. Provider business mailing address

35 WILDCAT WAY
KELLOGG ID
83837-2261
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-1351
  • Fax: 208-784-1356
Mailing address:
  • Phone: 208-784-1351
  • Fax: 208-784-1356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICKI MALONE
Title or Position: PROGRAM MANAGER
Credential:
Phone: 208-769-1406