Provider Demographics
NPI:1497887871
Name:IDAHO DEPT OF HEALTH &WELFARE REG 6 CMH PSR P
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH &WELFARE REG 6 CMH PSR P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:RITCHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-7900
Mailing Address - Street 1:421 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-234-7900
Mailing Address - Fax:208-236-6328
Practice Address - Street 1:421 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-234-7900
Practice Address - Fax:208-236-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0028412Medicaid
IDHW157OtherBLUE CROSS OF IDAHO
ID000010019402OtherBLUE SHIELD