Provider Demographics
NPI:1982045464
Name:AGENCY FOR CULTURAL ALLIANCE, LLC
Entity Type:Organization
Organization Name:AGENCY FOR CULTURAL ALLIANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BS,CPRP
Authorized Official - Phone:208-407-1857
Mailing Address - Street 1:1655 W FAIRVIEW AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5173
Mailing Address - Country:US
Mailing Address - Phone:208-407-1857
Mailing Address - Fax:208-906-8637
Practice Address - Street 1:1655 W FAIRVIEW AVE STE 103
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5173
Practice Address - Country:US
Practice Address - Phone:208-407-1857
Practice Address - Fax:208-906-8637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management