Provider Demographics
NPI:1700512860
Name:LATAH RECOVERY COMMUNITY CENTER, INC.
Entity Type:Organization
Organization Name:LATAH RECOVERY COMMUNITY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:KEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-883-1045
Mailing Address - Street 1:531 S MAIN
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843
Mailing Address - Country:US
Mailing Address - Phone:208-883-1045
Mailing Address - Fax:
Practice Address - Street 1:531 S MAIN
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-883-1045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty