Healthcare Provider Details

I. General information

NPI: 1811153844
Provider Name (Legal Business Name): EDWISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 FALLS AVE W #103
TWIN FALLS ID
83301-3359
US

IV. Provider business mailing address

1511 BUSCH CT
TWIN FALLS ID
83301-3476
US

V. Phone/Fax

Practice location:
  • Phone: 208-308-2410
  • Fax: 208-326-4343
Mailing address:
  • Phone: 208-308-2410
  • Fax: 208-326-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. PAMELA DAWN HOUSTON-POWELL
Title or Position: CO-PRESIDENT
Credential: ED.S
Phone: 208-308-2410