Provider Demographics
NPI:1720118904
Name:IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-334-0969
Mailing Address - Street 1:1720 WESTGATE DR
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7164
Mailing Address - Country:US
Mailing Address - Phone:208-334-0894
Mailing Address - Fax:208-334-0804
Practice Address - Street 1:2420 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3146
Practice Address - Country:US
Practice Address - Phone:208-587-9061
Practice Address - Fax:208-587-5024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8073418Medicaid
000010018973OtherBLUE SHIELD
HW280OtherBLUE CROSS OF IDAHO