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General NPI Number Information
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NPI Number | 1689133050
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Entity Type | Organization
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Legal Business Name | AMBITIONS OF IDAHO, INC.
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Dates
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Enumeration Date | 03/15/2019
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Last Update Date | 03/15/2019
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Provider Practice Location Address
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Address Line | 1044 NORTHWEST BLVD STE F
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2165
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Country | US
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Telephone | 208-676-9395
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Fax | 208-676-9385
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Provider Business Mailing Address
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Address Line | 1044 NORTHWEST BLVD STE F
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2165
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Country | US
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Telephone | 208-676-9395
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Fax | 208-676-9385
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHANE HAGEL
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Credential |
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Telephone | 208-676-9395
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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