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General NPI Number Information
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NPI Number | 1649539495
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Entity Type | Organization
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Legal Business Name | LATINO STAND UP IDAHO LLC
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Dates
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Enumeration Date | 05/15/2012
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Last Update Date | 05/20/2013
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Provider Practice Location Address
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Address Line | 1680 WOODRUFF PARK SUITE A
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3330
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Country | US
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Telephone | 208-346-2222
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Fax |
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Provider Business Mailing Address
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Address Line | 1680 WOODRUFF PARK SUITE A
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3330
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Country | US
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Telephone | 208-346-2222
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROGER T HORNE
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Credential |
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Telephone | 208-346-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State | ID
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Taxonomy #7
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State | ID
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Taxonomy #8
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | ID
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Taxonomy #9
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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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