Provider Demographics
NPI: | 1821205188 |
---|---|
Name: | EASTERN IDAHO PUBLIC HEALTH DISTRICT |
Entity Type: | Organization |
Organization Name: | EASTERN IDAHO PUBLIC HEALTH DISTRICT |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | WILLIAM |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | CORBETT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 208-522-0310 |
Mailing Address - Street 1: | 1250 HOLLIPARK DR |
Mailing Address - Street 2: | |
Mailing Address - City: | IDAHO FALLS |
Mailing Address - State: | ID |
Mailing Address - Zip Code: | 83401-6217 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 208-522-0310 |
Mailing Address - Fax: | 208-525-7063 |
Practice Address - Street 1: | 1250 HOLLIPARK DR |
Practice Address - Street 2: | |
Practice Address - City: | IDAHO FALLS |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83401-6217 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-522-0310 |
Practice Address - Fax: | 208-525-7063 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-05-17 |
Last Update Date: | 2023-08-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251K00000X | Agencies | Public Health or Welfare |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ID | 002471500 | Medicaid |