Provider Demographics
NPI:1164738134
Name:TREASURE VALLEY SERVICE COORDINATION
Entity Type:Organization
Organization Name:TREASURE VALLEY SERVICE COORDINATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:APPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-884-1030
Mailing Address - Street 1:1620 S CELEBRATION AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2779
Mailing Address - Country:US
Mailing Address - Phone:208-884-1030
Mailing Address - Fax:208-884-3058
Practice Address - Street 1:1620 S CELEBRATION AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2779
Practice Address - Country:US
Practice Address - Phone:208-884-1030
Practice Address - Fax:208-884-3058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TREASURE VALLEY PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807016700Medicaid