Provider Demographics
NPI:1689889073
Name:HUMAN DYNAMICS AND DIAGNOSTICS
Entity Type:Organization
Organization Name:HUMAN DYNAMICS AND DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-524-4953
Mailing Address - Street 1:2267 TETON PLZ
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6486
Mailing Address - Country:US
Mailing Address - Phone:208-524-4953
Mailing Address - Fax:208-524-7335
Practice Address - Street 1:2267 TETON PLZ
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6486
Practice Address - Country:US
Practice Address - Phone:208-524-4953
Practice Address - Fax:208-524-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807346900Medicaid