Provider Demographics
NPI:1447557335
Name:THE LILYPAD, LLC
Entity Type:Organization
Organization Name:THE LILYPAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-546-9723
Mailing Address - Street 1:PO BOX 1593
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-1593
Mailing Address - Country:US
Mailing Address - Phone:208-546-9723
Mailing Address - Fax:866-308-7175
Practice Address - Street 1:2010 W ROSTEN AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-4854
Practice Address - Country:US
Practice Address - Phone:208-546-9723
Practice Address - Fax:866-308-7175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDDA-1341251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0000393Medicaid