Provider Demographics
NPI:1639201593
Name:IDAHO DEPT OF HEALTH & WELFARE REG 7 CMH P C
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 7 CMH P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-528-5700
Mailing Address - Street 1:720 E ALICE PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0129
Mailing Address - Country:US
Mailing Address - Phone:208-785-5871
Mailing Address - Fax:208-785-5877
Practice Address - Street 1:720 E ALICE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-0129
Practice Address - Country:US
Practice Address - Phone:208-785-5871
Practice Address - Fax:208-785-5877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010019677OtherBLUE SHIELD
ID8073649Medicaid
IDHW157OtherBLUE CROSS