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General NPI Number Information
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NPI Number | 1922340124
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Entity Type | Organization
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Legal Business Name | HUMAN SUPPORTS OF IDAHO
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Dates
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Enumeration Date | 03/26/2013
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Last Update Date | 10/13/2022
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Provider Practice Location Address
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Address Line | 4477 W EMERALD ST STE C-100
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City | BOISE
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State | ID
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Zip | 83706-2000
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Country | US
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Telephone | 208-454-8389
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Fax | 208-454-8404
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Provider Business Mailing Address
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Address Line | PO BOX 820
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City | CALDWELL
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State | ID
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Zip | 83606-0820
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Country | US
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Telephone | 208-454-8389
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Fax | 208-454-8404
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Authorized Official
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Title or Position | ADMINISTRATEIVE SERVICES MANAGER
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Name | ALITA RUBY
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Credential |
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Telephone | 208-454-8389
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State | ID
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