Provider Demographics
NPI:1457696551
Name:NORTH IDAHO COLLEGE
Entity Type:Organization
Organization Name:NORTH IDAHO COLLEGE
Other - Org Name:AREA AGENCY ON AGING OF NORTH IDAHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PEARL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-3179
Mailing Address - Street 1:2120 N LAKEWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2638
Mailing Address - Country:US
Mailing Address - Phone:208-667-3179
Mailing Address - Fax:208-667-5938
Practice Address - Street 1:2120 N LAKEWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2638
Practice Address - Country:US
Practice Address - Phone:208-667-3179
Practice Address - Fax:208-667-5938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH IDAHO COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ID171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID193200000XOtherMULTI SPECIALTY
ID251B00000XOtherCASE MANAGEMENT
ID171M00000XOtherCARE MANAGMENT CARE COORDINATOR
ID251V00000XOtherVOLUNTARY OR CHARITABLE