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General NPI Number Information
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NPI Number | 1982045464
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Entity Type | Organization
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Legal Business Name | AGENCY FOR CULTURAL ALLIANCE, LLC
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Dates
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Enumeration Date | 07/11/2013
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Last Update Date | 08/19/2013
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Provider Practice Location Address
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Address Line | 1655 W FAIRVIEW AVE STE 103
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City | BOISE
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State | ID
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Zip | 83702-5173
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Country | US
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Telephone | 208-407-1857
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Fax | 208-906-8637
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Provider Business Mailing Address
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Address Line | 1655 W FAIRVIEW AVE STE 103
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City | BOISE
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State | ID
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Zip | 83702-5173
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Country | US
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Telephone | 208-407-1857
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Fax | 208-906-8637
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Authorized Official
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Title or Position | LLC MEMBER/MANAGER
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Name | MRS. STACEY ANN MARTINEZ
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Credential | BS,CPRP
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Telephone | 208-407-1857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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