Provider Demographics
NPI:1376935494
Name:APEX ADVENTURE THERAPY
Entity Type:Organization
Organization Name:APEX ADVENTURE THERAPY
Other - Org Name:BLUEFIRE WILDERNESS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:REX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-308-3163
Mailing Address - Street 1:1832 E 1750 S
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-5177
Mailing Address - Country:US
Mailing Address - Phone:208-934-4444
Mailing Address - Fax:208-934-5171
Practice Address - Street 1:1832 E 1750 S
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5177
Practice Address - Country:US
Practice Address - Phone:208-934-4444
Practice Address - Fax:208-934-5171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID38122322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children