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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