# LATINO STAND UP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1164781365
- **Authorized official:** MR. ROGER T HORNE (OWNER)
- **Authorized official phone:** (910) 573-0861

## Contact information

- **Practice address:** 1420 E 17TH ST STE E, IDAHO FALLS, ID 83404-6283
- **Practice address phone:** (208) 528-5434
- **Practice address fax:** (208) 522-4364
- **Mailing address:** 1420 E 17TH ST STE E, IDAHO FALLS, ID 83404-6283
- **Mailing address phone:** (208) 528-5434
- **Mailing address fax:** (208) 522-4364

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM0850X | Adult Mental Health Clinic/Center | — | NULL | — |
| 261QM0855X | Adolescent and Children Mental Health Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 05/08/2012
- **Last updated:** 03/31/2013