Provider Demographics
NPI:1447557772
Name:IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-769-1406
Mailing Address - Street 1:35 WILDCAT WAY
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2261
Mailing Address - Country:US
Mailing Address - Phone:208-784-1351
Mailing Address - Fax:208-784-1356
Practice Address - Street 1:35 WILDCAT WAY
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2261
Practice Address - Country:US
Practice Address - Phone:208-784-1351
Practice Address - Fax:208-784-1356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010018348OtherBLUE SHIELD
IDHW256OtherBLUE CROSS