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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