Provider Demographics
NPI: | 1174860894 |
---|---|
Name: | DIRNE HEALTH CENTERS INC |
Entity Type: | Organization |
Organization Name: | DIRNE HEALTH CENTERS INC |
Other - Org Name: | HERITAGE BEHAVIORAL HEALTH |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MIKE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BAKER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 208-620-5210 |
Mailing Address - Street 1: | PO BOX 1387 |
Mailing Address - Street 2: | |
Mailing Address - City: | HAYDEN |
Mailing Address - State: | ID |
Mailing Address - Zip Code: | 83835-1387 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 208-415-0299 |
Mailing Address - Fax: | 204-625-2070 |
Practice Address - Street 1: | 2025 W PARK PL |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | COEUR D ALENE |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83814-2787 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-292-0292 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | DIRNE HEALTH CENTERS INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2013-01-15 |
Last Update Date: | 2023-03-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YS0200X | Behavioral Health & Social Service Providers | Counselor | School | Group - Multi-Specialty |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 175T00000X | Other Service Providers | Peer Specialist | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RA0401X | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ID | 131850 | Medicare Oscar/Certification | |
ID | 1378465 | Medicare PIN |