Provider Demographics
NPI:1639476294
Name:IDAHO DEPT OF HEALTH & WELFARE REG 2 CMH
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 2 CMH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-799-4440
Mailing Address - Street 1:1350 TROY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3995
Mailing Address - Country:US
Mailing Address - Phone:208-882-0562
Mailing Address - Fax:
Practice Address - Street 1:1350 TROY HIGHWAY
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3995
Practice Address - Country:US
Practice Address - Phone:208-882-0562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010018450OtherBLUE SHIELD
IDHW140OtherBLUE CROSS