Healthcare Provider Details

I. General information

NPI: 1689895625
Provider Name (Legal Business Name): VCC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 EASTLAND DR N STE C
TWIN FALLS ID
83301-8442
US

IV. Provider business mailing address

1092 EASTLAND DR N STE C
TWIN FALLS ID
83301-8442
US

V. Phone/Fax

Practice location:
  • Phone: 208-736-0695
  • Fax: 208-735-2482
Mailing address:
  • Phone: 208-736-0695
  • Fax: 208-735-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CARLA DEJONG
Title or Position: OWNER
Credential:
Phone: 208-736-0695