Provider Demographics
NPI:1689820375
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:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KROSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-455-5300
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:208-455-5300
Mailing Address - Fax:
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:208-455-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1910067Medicare UPIN