Provider Demographics
NPI:1598748337
Name:SOUTHWEST DISTRICT HEALTH
Entity Type:Organization
Organization Name:SOUTHWEST DISTRICT HEALTH
Other - Org Name:STATE OF IDAHO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE SPECIALIST II
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-455-5348
Mailing Address - Street 1:13307 MIAMI LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-4701
Mailing Address - Country:US
Mailing Address - Phone:208-455-5305
Mailing Address - Fax:208-455-5368
Practice Address - Street 1:13307 MIAMI LN
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-4701
Practice Address - Country:US
Practice Address - Phone:208-455-5305
Practice Address - Fax:208-455-5368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI002824100Medicaid
ID002828400Medicaid
ID002821600Medicaid
ID805201700Medicaid
ID002828400Medicaid
HI002824100Medicaid