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Organization
LATINO STAND UP
Active
Organization
LATINO STAND UP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROGER T HORNE (OWNER)
(910) 573-0861
Entity
Organization
Contact information
Practice address
1420 E 17TH ST STE E, IDAHO FALLS, ID 83404-6283
(208) 528-5434
(208) 522-4364
Mailing address
1420 E 17TH ST STE E, IDAHO FALLS, ID 83404-6283
(208) 528-5434
(208) 522-4364
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
—
NULL
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
NULL
Other
Enumeration date
05/08/2012
Last updated
03/31/2013
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