Provider Demographics
NPI:1477839744
Name:COLLEGE OF SOUTHERN IDAHO
Entity Type:Organization
Organization Name:COLLEGE OF SOUTHERN IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN OF HSHS BUILDING
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-732-6849
Mailing Address - Street 1:315 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3367
Mailing Address - Country:US
Mailing Address - Phone:208-732-6221
Mailing Address - Fax:208-736-4743
Practice Address - Street 1:315 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3367
Practice Address - Country:US
Practice Address - Phone:208-732-6751
Practice Address - Fax:208-736-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental