Provider Demographics
NPI:1417370990
Name:WELLNESS ENHANCEMENT CENTER OF IDAHO INC.
Entity Type:Organization
Organization Name:WELLNESS ENHANCEMENT CENTER OF IDAHO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-503-6298
Mailing Address - Street 1:1111 W IRONWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2604
Mailing Address - Country:US
Mailing Address - Phone:208-664-1594
Mailing Address - Fax:208-664-5867
Practice Address - Street 1:1111 W IRONWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2604
Practice Address - Country:US
Practice Address - Phone:208-664-1594
Practice Address - Fax:208-664-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMHC-421251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807823900Medicaid