Provider Demographics
NPI:1245368539
Name:IDAHODHWBH3 NAMPA CMH PSR
Entity type:Organization
Organization Name:IDAHODHWBH3 NAMPA CMH PSR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIELD OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-455-7057
Mailing Address - Street 1:823 PARKCENTRE WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1783
Mailing Address - Country:US
Mailing Address - Phone:208-465-8452
Mailing Address - Fax:208-465-8431
Practice Address - Street 1:823 PARKCENTRE WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1783
Practice Address - Country:US
Practice Address - Phone:208-465-8452
Practice Address - Fax:208-465-8431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
HW348OtherBLUE CROSS OF IDAHO
000010018824OtherBLUESHIELD
ID8073441Medicaid