Provider Demographics
NPI:1700913340
Name:IDAHO DHWBH3 CALDAMHCLINIC
Entity Type:Organization
Organization Name:IDAHO DHWBH3 CALDAMHCLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIELD OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-455-7057
Mailing Address - Street 1:3402 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6932
Mailing Address - Country:US
Mailing Address - Phone:208-459-0092
Mailing Address - Fax:208-454-7714
Practice Address - Street 1:3402 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6932
Practice Address - Country:US
Practice Address - Phone:208-459-0092
Practice Address - Fax:208-454-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDHW298OtherBLUE CROSS OF IDAHO
ID000010027633OtherBLUESHIELD
ID8062827Medicaid