Provider Demographics
NPI:1326680422
Name:CROSSROADS HEALTH IDAHO LLC
Entity Type:Organization
Organization Name:CROSSROADS HEALTH IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-256-7888
Mailing Address - Street 1:1851 MADISON AVE STE 718
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3602
Mailing Address - Country:US
Mailing Address - Phone:712-256-7888
Mailing Address - Fax:712-256-6502
Practice Address - Street 1:8950 W EMERALD ST STE 178
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8296
Practice Address - Country:US
Practice Address - Phone:208-376-7083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS OF WESTERN IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty