Provider Demographics
NPI:1063839124
Name:CITY OF BLACKFOOT
Entity Type:Organization
Organization Name:CITY OF BLACKFOOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:POOL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHANTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-8625
Mailing Address - Street 1:960 S FISHER AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3370
Mailing Address - Country:US
Mailing Address - Phone:208-785-8625
Mailing Address - Fax:
Practice Address - Street 1:960 S FISHER AVE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3370
Practice Address - Country:US
Practice Address - Phone:208-785-8625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service