Provider Demographics
NPI:1518314145
Name:TREASURE VALLEY ADVANCED CONCEPTS LLC
Entity Type:Organization
Organization Name:TREASURE VALLEY ADVANCED CONCEPTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:GUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:208-573-1576
Mailing Address - Street 1:210 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5104
Mailing Address - Country:US
Mailing Address - Phone:208-573-1576
Mailing Address - Fax:
Practice Address - Street 1:210 HOLLY ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5104
Practice Address - Country:US
Practice Address - Phone:208-573-1576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management