Provider Demographics
NPI:1326176132
Name:IDAHO DEPT OF HEALTH & WELFARE REG II AMH MOSCOW
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG II AMH MOSCOW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:208-799-4440
Mailing Address - Street 1:1350 TROY HWY
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3995
Mailing Address - Country:US
Mailing Address - Phone:208-882-0562
Mailing Address - Fax:208-882-8575
Practice Address - Street 1:1350 TROY HWY
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3995
Practice Address - Country:US
Practice Address - Phone:208-882-0562
Practice Address - Fax:208-882-8575
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
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8073803Medicaid
HW264OtherBLUE CROSS OF IDAHO
000010018440OtherBLUE SHIELD