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Organization
LATINO STAND UP IDAHO LLC
Active
Organization
LATINO STAND UP IDAHO LLC
Active
Other names
Latino Stand Up
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROGER HORNE (OWNER)
(910) 573-0861
Entity
Organization
Contact information
Practice address
1680 WOODRUFF PARK, IDAHO FALLS, ID 83401-3330
(208) 552-6373
(208) 552-2188
Mailing address
1680 WOODRUFF PARK, IDAHO FALLS, ID 83401-3330
(208) 552-6373
(208) 552-2188
Taxonomy
Speciality
Code
Description
License number
State
2084P0804X
Child & Adolescent Psychiatry Physician
—
—
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
363AM0700X
Medical Physician Assistant
—
—
364S00000X
Clinical Nurse Specialist
—
—
Other
Enumeration date
12/28/2012
Last updated
05/23/2013
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