Provider Demographics
NPI:1396921581
Name:MERIDIAN DEVELOPMENTAL SERVICES LLC
Entity type:Organization
Organization Name:MERIDIAN DEVELOPMENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-888-6068
Mailing Address - Street 1:40 W FRANKLIN RD STE I
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2992
Mailing Address - Country:US
Mailing Address - Phone:208-888-6068
Mailing Address - Fax:208-888-6055
Practice Address - Street 1:40 W FRANKLIN RD STE I
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2992
Practice Address - Country:US
Practice Address - Phone:208-888-6068
Practice Address - Fax:208-888-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services