Provider Demographics
NPI:1396907861
Name:ALL DEVELOPMENTAL DISABILITY SERVICES
Entity type:Organization
Organization Name:ALL DEVELOPMENTAL DISABILITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:208-465-5114
Mailing Address - Street 1:2717 S KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5623
Mailing Address - Country:US
Mailing Address - Phone:208-465-5114
Mailing Address - Fax:208-465-5198
Practice Address - Street 1:1350 S VISTA AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2567
Practice Address - Country:US
Practice Address - Phone:208-424-3160
Practice Address - Fax:208-433-9794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808063101Medicaid
ID808077800Medicaid
ID808317200Medicaid
ID808065600Medicaid
ID808063100Medicaid
ID808077801Medicaid
ID808065601Medicaid