Provider Demographics
NPI:1588041537
Name:UNIFIED HEALTHCARE OF IDAHO LLC
Entity Type:Organization
Organization Name:UNIFIED HEALTHCARE OF IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-221-0007
Mailing Address - Street 1:2275 W BROADWAY ST STE G
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2902
Mailing Address - Country:US
Mailing Address - Phone:208-529-3967
Mailing Address - Fax:208-522-0088
Practice Address - Street 1:2275 W BROADWAY ST STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-529-3967
Practice Address - Fax:208-522-0088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUELLER COUNSELING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-29
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID847298396Medicaid