Provider Demographics
NPI:1396919916
Name:SOUTHEASTERN DISTRICT HEALTH DEPT.
Entity type:Organization
Organization Name:SOUTHEASTERN DISTRICT HEALTH DEPT.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACHS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:NANNETTE
Authorized Official - Last Name:CODDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-9080
Mailing Address - Street 1:1901 ALVIN RICKEN DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2727
Mailing Address - Country:US
Mailing Address - Phone:208-233-9080
Mailing Address - Fax:208-234-7169
Practice Address - Street 1:1901 ALVIN RICKEN DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2727
Practice Address - Country:US
Practice Address - Phone:208-233-9080
Practice Address - Fax:208-234-7169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID600000697Medicare PIN
ID1910049Medicare PIN