Organization
IDAHO DEPARTMENT OF HEALTH AND WELFARE, BUREAU OF LABORATORIES
Active
Organization
IDAHO DEPARTMENT OF HEALTH AND WELFARE, BUREAU OF LABORATORIES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELKE SHAW-TULLOCH MHS (DIVISION ADMINISTRATOR & STATE HEAL)
(208) 334-6996
Entity
Organization
Contact information
Practice address
2220 OLD PENITENTIARY RD, BOISE, ID 83712-8299
(208) 334-2235
(208) 334-4765
Mailing address
2220 OLD PENITENTIARY RD, BOISE, ID 83712-8299
(208) 334-2235
(208) 334-4765
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010007987
BLUE SHIELD REGENCE
ID
05
—
0028335
—
ID
01
—
87320
BLUE CROSS OF IDAHO
ID
Enumeration date
03/07/2007
Last updated
10/24/2019
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