Provider Demographics
NPI:1821388505
Name:TW MCKNIGHT ENTERPRISES
Entity Type:Organization
Organization Name:TW MCKNIGHT ENTERPRISES
Other - Org Name:LIFESPAN FAMILY PRACTICE MENTAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-736-7090
Mailing Address - Street 1:550 POLK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3916
Mailing Address - Country:US
Mailing Address - Phone:208-736-7090
Mailing Address - Fax:208-736-7089
Practice Address - Street 1:550 POLK ST
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3916
Practice Address - Country:US
Practice Address - Phone:208-736-7090
Practice Address - Fax:208-736-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPENDINGMedicaid