Provider Demographics
NPI:1417083833
Name:IDAHO DEPT OF HEALTH & WELFARE REGION 7 CMH PSR SALMON
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REGION 7 CMH PSR SALMON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-528-5706
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-0610
Mailing Address - Country:US
Mailing Address - Phone:208-756-3336
Mailing Address - Fax:208-756-3805
Practice Address - Street 1:1301 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4451
Practice Address - Country:US
Practice Address - Phone:208-756-3336
Practice Address - Fax:208-756-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010019677OtherBLUE SHIELD
ID8073788Medicaid
HW157OtherBLUE CROSS OF IDAHO