Provider Demographics
NPI:1477816809
Name:FAMILY AND ADOLESCENT CARE OF TWIN FALLS PA
Entity Type:Organization
Organization Name:FAMILY AND ADOLESCENT CARE OF TWIN FALLS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCARI
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:208-731-6971
Mailing Address - Street 1:476 CHENEY DRIVE WEST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-944-0497
Mailing Address - Fax:208-944-0506
Practice Address - Street 1:476 CHENEY DRIVE WEST
Practice Address - Street 2:SUITE 160
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-944-0497
Practice Address - Fax:208-944-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-986A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty