Healthcare Provider Details

I. General information

NPI: 1104419423
Provider Name (Legal Business Name): A2C CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W CEDAR ST STE 3
POCATELLO ID
83201-5045
US

IV. Provider business mailing address

333 W CEDAR ST STE 3
POCATELLO ID
83201-5045
US

V. Phone/Fax

Practice location:
  • Phone: 208-252-5621
  • Fax: 208-648-4167
Mailing address:
  • Phone: 208-252-5621
  • Fax: 208-648-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STACY HUMPHERYS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-252-5621