=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023483211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FAMILY TABLE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2015
-----------------------------------------------------
Last Update Date | 12/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 E FRANKLIN RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-855-9302
-----------------------------------------------------
Fax | 208-855-9303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 39
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83680-0039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-855-9302
-----------------------------------------------------
Fax | 208-855-9303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHRISTOPHER AMES HEINDEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-855-9302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------