Provider Demographics
NPI:1881852036
Name:RBTD INCORPORATED
Entity Type:Organization
Organization Name:RBTD INCORPORATED
Other - Org Name:IMPACT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/LSW
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:208-522-8899
Mailing Address - Street 1:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2106
Mailing Address - Country:US
Mailing Address - Phone:208-745-7831
Mailing Address - Fax:208-745-7831
Practice Address - Street 1:152 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5268
Practice Address - Country:US
Practice Address - Phone:208-745-7831
Practice Address - Fax:208-745-0658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807776700Medicaid