Provider Demographics
NPI:1558497966
Name:IDAHO DEPARTMENT OF HEALTH & WELFARE REGION 7 AMH CLINIC IF
Entity Type:Organization
Organization Name:IDAHO DEPARTMENT OF HEALTH & WELFARE REGION 7 AMH CLINIC IF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-528-5706
Mailing Address - Street 1:150 SHOUP AVE
Mailing Address - Street 2:SUITE 17
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3657
Mailing Address - Country:US
Mailing Address - Phone:208-528-5700
Mailing Address - Fax:208-528-5747
Practice Address - Street 1:150 SHOUP AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3657
Practice Address - Country:US
Practice Address - Phone:208-528-5700
Practice Address - Fax:208-528-5747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8061288Medicaid
HW181OtherBLUE CROSS OF IDAHO
000010019677OtherBLUE SHIELD