Provider Demographics
NPI:1063671469
Name:ADOLESCENT & CHILD DEVELOPMENT CENTER, LLC
Entity Type:Organization
Organization Name:ADOLESCENT & CHILD DEVELOPMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-232-5622
Mailing Address - Street 1:151 N 3RD AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6331
Mailing Address - Country:US
Mailing Address - Phone:208-232-5622
Mailing Address - Fax:208-233-4639
Practice Address - Street 1:151 N 3RD AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6331
Practice Address - Country:US
Practice Address - Phone:208-232-5622
Practice Address - Fax:208-233-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QD1600X261QD1600X
ID261QM0801X261QM0801X
ID261QM0850X261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808259000Medicaid
ID808257100Medicaid
ID808028200Medicaid