=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962658500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYRINGA FAMILY PARTNERSHIP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2008
-----------------------------------------------------
Last Update Date | 08/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3650 N GOVERNMENT WAY SUITE L
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-8331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-676-1693
-----------------------------------------------------
Fax | 208-676-1030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 844
-----------------------------------------------------
City | HAYDEN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-0844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-771-1551
-----------------------------------------------------
Fax | 208-676-1030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / DIRECTOR
-----------------------------------------------------
Name | MRS. COLLEEN IRENE SISK
-----------------------------------------------------
Credential | BSW
-----------------------------------------------------
Telephone | 208-771-1551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------