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General NPI Number Information
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NPI Number | 1114058179
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Entity Type | Organization
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Legal Business Name | IDAHO DEPT OF HEALTH & WELFARE REG 7 AMH BF
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 08/10/2010
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Provider Practice Location Address
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Address Line | 720 E ALICE
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City | BLACKFOOT
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State | ID
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Zip | 83221-0129
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Country | US
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Telephone | 208-785-5871
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Fax | 208-785-5877
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Provider Business Mailing Address
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Address Line | 720 E ALICE PO BOX 129
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City | BLACKFOOT
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State | ID
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Zip | 83221-0129
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Country | US
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Telephone | 208-785-5871
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Fax | 208-785-5877
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Authorized Official
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Title or Position | PROGRAM MANAGER
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Name | RANDY RODRIQUEZ II
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Credential | LCSW
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Telephone | 208-528-5700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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License Number State |
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