Provider Demographics
NPI:1295589935
Name:CAMERON STALEY PHD LLC
Entity type:Organization
Organization Name:CAMERON STALEY PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-269-5475
Mailing Address - Street 1:5026 CASSIE DR
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5252
Mailing Address - Country:US
Mailing Address - Phone:801-644-2006
Mailing Address - Fax:
Practice Address - Street 1:5026 CASSIE DR
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5252
Practice Address - Country:US
Practice Address - Phone:801-644-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health