=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285886697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMILTON TREATMENT ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 10/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 YELLOWSTONE AVE STE 211
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-4569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-479-9149
-----------------------------------------------------
Fax | 208-233-4458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 RIMVIEW DR
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-8467
-----------------------------------------------------
Fax | 208-233-4458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. DOROTHY ANNE HAMILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-733-8467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------