Healthcare Provider Details

I. General information

NPI: 1285776112
Provider Name (Legal Business Name): COUNTY OF LATAH 285 SCHOOL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136TH STREET
POTLATCH ID
83855
US

IV. Provider business mailing address

104 E FAIRVIEW AVE STE 201
MERIDIAN ID
83642-1733
US

V. Phone/Fax

Practice location:
  • Phone: 208-875-0327
  • Fax: 208-875-1028
Mailing address:
  • Phone: 208-922-3093
  • Fax: 208-922-9351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateID

VIII. Authorized Official

Name: TODD KENNETH LEVESQUE
Title or Position: SYSTEMS MANAGER
Credential:
Phone: 208-922-3093