Provider Demographics
NPI:1275664583
Name:IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:AXFORD
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:208-234-7900
Mailing Address - Street 1:421 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-234-7900
Mailing Address - Fax:208-236-6328
Practice Address - Street 1:223 N STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1140
Practice Address - Country:US
Practice Address - Phone:208-852-0634
Practice Address - Fax:208-852-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDHW108OtherBLUE CROSS OF IDAHO
ID000010019235OtherBLUE SHIELD
ID8073684Medicaid