MEDICARE: COUNTY OF ELMOR CONSOLIDATED CLASS A 192

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	251300000X	Local Education Agency (LEA)		ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629114939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF ELMOR CONSOLIDATED CLASS A 192

Provider Business Mailing Address
First Line	:	104 E FAIRVIEW AVE STE 201
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-1733
Country	:	US
Telephone Number	:	208-922-3093
Fax Number	:	208-922-9351

Provider Business Practice Location Address
First Line	:	800 OLD HWY 30
Second Line	:
City	:	GLENNS FERRY
State	:	ID
Zip	:	83623
Country	:	US
Telephone Number	:	208-366-7434
Fax Number	:	208-366-7455

Authorized Official
Title or Position	:	SYSTEMS MANAGER
Name	:	MR. TODD KENNETH LEVESQUE
Credential	:
Telephone Number	:	208-922-3093

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/07/2008

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