Provider Demographics
NPI:1952474777
Name:IDAHO STATE UNIVERSITY
Entity type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICS DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-373-1743
Mailing Address - Street 1:921 S 8TH AVE STOP 8116
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0002
Mailing Address - Country:US
Mailing Address - Phone:208-282-3495
Mailing Address - Fax:208-282-4571
Practice Address - Street 1:650 MEMORIAL DRIVE
Practice Address - Street 2:BLDG #68
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-282-3495
Practice Address - Fax:208-282-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1373755Medicare ID - Type UnspecifiedGROUP NUMBER