=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700906054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERIDIAN DEVELOPMENTAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 W FRANKLIN RD STE I
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-2992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-6068
-----------------------------------------------------
Fax | 208-888-6055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 140289
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83714-0289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-853-7155
-----------------------------------------------------
Fax | 208-853-7156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JERRY R. FOWLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-853-7155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------