=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518022342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 02/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 E ALICE ST BOX 400
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-4925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-1200
-----------------------------------------------------
Fax | 208-785-8518
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 EAST ALICE STREET PO BOX 400
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-1200
-----------------------------------------------------
Fax | 208-785-8518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | MRS. TRACEY G. SESSIONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-785-8402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | H17
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------