Provider Demographics
NPI:1376670091
Name:IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH PSR BONNERS FERRY
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH PSR BONNERS FERRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORA JO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSSENHOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-769-1406
Mailing Address - Street 1:RT 4 6522 TAMARACK LN
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-9805
Mailing Address - Country:US
Mailing Address - Phone:208-267-3187
Mailing Address - Fax:208-267-3251
Practice Address - Street 1:RT 4 6522 TAMARACK LN
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-9805
Practice Address - Country:US
Practice Address - Phone:208-267-3187
Practice Address - Fax:208-267-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
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
ID8073521Medicaid
000010018348OtherBLUE SHIELD
HW256OtherBLUE CROSS OF IDAHO