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General NPI Number Information
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NPI Number | 1063671469
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Entity Type | Organization
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Legal Business Name | ADOLESCENT & CHILD DEVELOPMENT CENTER, LLC
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Dates
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Enumeration Date | 06/02/2008
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Last Update Date | 04/02/2009
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Provider Practice Location Address
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Address Line | 151 N 3RD AVE SUITE 110
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City | POCATELLO
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State | ID
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Zip | 83201-6331
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Country | US
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Telephone | 208-232-5622
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Fax | 208-233-4639
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Provider Business Mailing Address
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Address Line | 151 N 3RD AVE SUITE 110
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City | POCATELLO
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State | ID
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Zip | 83201-6331
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Country | US
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Telephone | 208-232-5622
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Fax | 208-233-4639
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Authorized Official
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Title or Position | OWNER/EXECUTIVE DIRECTOR
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Name | MR. VANCE RAY WALKER
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Credential |
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Telephone | 208-232-5622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 261QM0850X
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 261QM0801X
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number | 261QD1600X
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License Number State | ID
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