Provider Demographics
NPI:1811028889
Name:IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH CLINIC POC
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH CLINIC POC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:AXFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-7900
Mailing Address - Street 1:421 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-234-7900
Mailing Address - Fax:208-236-6328
Practice Address - Street 1:421 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-234-7900
Practice Address - Fax:208-236-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010019235OtherBLUE SHIELD
IDHW108OtherBLUE CROSS OF IDAHO
ID0028475Medicaid