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General NPI Number Information
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NPI Number | 1457696551
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Entity Type | Organization
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Legal Business Name | NORTH IDAHO COLLEGE
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Dates
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Enumeration Date | 11/30/2012
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Last Update Date | 11/30/2012
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Provider Practice Location Address
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Address Line | 2120 N LAKEWOOD DR STE B
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2638
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Country | US
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Telephone | 208-667-3179
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Fax | 208-667-5938
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Provider Business Mailing Address
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Address Line | 2120 N LAKEWOOD DR STE B
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2638
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Country | US
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Telephone | 208-667-3179
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Fax | 208-667-5938
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Authorized Official
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Title or Position | DIRECTOR
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Name | PEARL BOUCHARD
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Credential |
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Telephone | 208-667-3179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State | ID
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