Provider Demographics
NPI:1568636959
Name:SOUTHEASTERN IDAHO DEVELOPMENTAL CENTER, INC .
Entity Type:Organization
Organization Name:SOUTHEASTERN IDAHO DEVELOPMENTAL CENTER, INC .
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-782-1301
Mailing Address - Street 1:PO BOX 701
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0701
Mailing Address - Country:US
Mailing Address - Phone:208-782-1301
Mailing Address - Fax:208-782-3627
Practice Address - Street 1:765 W JUDICIAL ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2036
Practice Address - Country:US
Practice Address - Phone:208-782-1301
Practice Address - Fax:208-782-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8068453Medicaid