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General NPI Number Information
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NPI Number | 1700512860
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Entity Type | Organization
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Legal Business Name | LATAH RECOVERY COMMUNITY CENTER, INC.
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Dates
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Enumeration Date | 07/29/2022
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Last Update Date | 07/29/2022
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Provider Practice Location Address
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Address Line | 531 S MAIN
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City | MOSCOW
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State | ID
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Zip | 83843
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Country | US
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Telephone | 208-883-1045
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Fax |
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Provider Business Mailing Address
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Address Line | 531 S MAIN
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City | MOSCOW
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State | ID
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Zip | 83843
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Country | US
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Telephone | 208-883-1045
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DARRELL ERIC KEIM
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Credential |
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Telephone | 208-883-1045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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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 | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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