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General NPI Number Information
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NPI Number | 1619119864
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Entity Type | Organization
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Legal Business Name | AHS OF IDAHO
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Dates
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Enumeration Date | 04/02/2009
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Last Update Date | 04/02/2009
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Provider Practice Location Address
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Address Line | 911 PREACHER CREEK RD
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City | SHOSHONE
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State | ID
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Zip | 83352-5061
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Country | US
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Telephone | 208-886-2565
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Fax | 208-886-2153
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Provider Business Mailing Address
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Address Line | 911 PREACHER CREEK RD
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City | SHOSHONE
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State | ID
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Zip | 83352-5061
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Country | US
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Telephone | 208-886-2565
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Fax | 208-886-2153
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. KATHY REX
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Credential | CRT
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Telephone | 208-886-2565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 25860
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License Number State | ID
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