MEDICARE: LDS FAMILY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	21136	ID

General Provider Information

NPI Number	:	1013122563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LDS FAMILY SERVICES

Provider Business Mailing Address
First Line	:	1418 FILLMORE ST
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3380
Country	:	US
Telephone Number	:	208-735-2237
Fax Number	:	208-735-8552

Provider Business Practice Location Address
First Line	:	1418 FILLMORE ST
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3380
Country	:	US
Telephone Number	:	208-735-2237
Fax Number	:	208-735-8552

Authorized Official
Title or Position	:	AGENCY DIRECTOR
Name	:	LORI THROCKMORTON
Credential	:
Telephone Number	:	208-376-0191

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	06/04/2008

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