Provider Demographics
NPI:1528197514
Name:IDAHO DEPT. OF HEALTH & WELFARE REG II CMH LEWISTON
Entity Type:Organization
Organization Name:IDAHO DEPT. OF HEALTH & WELFARE REG II CMH LEWISTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:208-799-4440
Mailing Address - Street 1:1118 F ST
Mailing Address - Street 2:DRAWER B
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1930
Mailing Address - Country:US
Mailing Address - Phone:208-799-4360
Mailing Address - Fax:208-799-3317
Practice Address - Street 1:1118 F ST
Practice Address - Street 2:DRAWER B
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1930
Practice Address - Country:US
Practice Address - Phone:208-799-4360
Practice Address - Fax:208-799-3317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010018450OtherBLUE SHIELD
HW140OtherBLUE CROSS OF IDAHO
ID0028418Medicaid