Provider Demographics
NPI:1821263088
Name:HUMPHREYS DIABETES CENTER
Entity Type:Organization
Organization Name:HUMPHREYS DIABETES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-331-1155
Mailing Address - Street 1:1226 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7049
Mailing Address - Country:US
Mailing Address - Phone:208-331-1155
Mailing Address - Fax:208-383-0190
Practice Address - Street 1:1226 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7049
Practice Address - Country:US
Practice Address - Phone:208-331-1155
Practice Address - Fax:208-383-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY331103T00000X
IDD33630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8G502OtherBLUE CROSS
ID806348400Medicaid
ID1374744OtherMEDICARE MNT