Provider Demographics
NPI:1154459444
Name:IDAHODHWBH3 PAYETTE CMH PSR
Entity Type:Organization
Organization Name:IDAHODHWBH3 PAYETTE CMH PSR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIELD OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-455-7057
Mailing Address - Street 1:515 16TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2047
Mailing Address - Country:US
Mailing Address - Phone:208-642-6416
Mailing Address - Fax:208-642-2829
Practice Address - Street 1:515 16TH AVE N
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2047
Practice Address - Country:US
Practice Address - Phone:208-642-6416
Practice Address - Fax:208-642-2829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8073442Medicaid
HW348OtherBLUE CROSS OF IDAHO
000010018824OtherBLUESHIELD