Provider Demographics
NPI:1790841781
Name:STATE OF IDAHO
Entity Type:Organization
Organization Name:STATE OF IDAHO
Other - Org Name:STATE HOSPITAL SOUTH LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:HECKARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-785-8429
Mailing Address - Street 1:BOX 400
Mailing Address - Street 2:700 EAST ALICE
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-785-8429
Mailing Address - Fax:208-785-8439
Practice Address - Street 1:700 EAST ALICE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-8429
Practice Address - Fax:208-785-8439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory