Healthcare Provider Details

I. General information

NPI: 1932084688
Provider Name (Legal Business Name): ALEXANDER SHRIVER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 W CAYUSE CREEK DR STE 100
MERIDIAN ID
83646-4795
US

IV. Provider business mailing address

1548 W CAYUSE CREEK DR STE 100
MERIDIAN ID
83646-4795
US

V. Phone/Fax

Practice location:
  • Phone: 208-600-2072
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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:
Title or Position:
Credential:
Phone: