Provider Demographics
NPI:1205863222
Name:FAMILY CARE CENTER, INC
Entity type:Organization
Organization Name:FAMILY CARE CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:2085-298-8332
Mailing Address - Street 1:1582 N HOLMES AVENUE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2032
Mailing Address - Country:US
Mailing Address - Phone:208-529-8832
Mailing Address - Fax:208-535-7595
Practice Address - Street 1:1582 N HOLMES AVENUE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2032
Practice Address - Country:US
Practice Address - Phone:208-524-8832
Practice Address - Fax:208-535-7595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101Y00000X, 103T00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648300Medicaid
ID000010006240OtherBLUE SHIELD OF IDAHO
ID8333-7OtherBLUE CROSS OF IDAHO
ID=========OtherTAX IDENTIFICATION