Organization
IDAHO DEPT OF HEALTH & WELFARE ITP REGION 2
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MARY J JONES B.U.S. (PROGRAM MANAGER)
(208) 334-5523
Entity
Organization
Contact information
Practice address
2604 16TH AVE, LEWISTON, ID 83501-3539
(208) 799-3460
(208) 799-3466
Mailing address
1118 F ST, PO DRAWER B, LEWISTON, ID 83501-1930
(208) 799-3460
(208) 799-3466
Taxonomy
Speciality
Code
Description
License number
State
251300000X
Local Education Agency (LEA)
—
—
252Y00000X
Early Intervention Provider Agency
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018383
BLUE SHIELD
ID
05
—
0028421
—
ID
01
—
HW132
BLUE CROSS OF IDAHO
ID
Enumeration date
02/05/2007
Last updated
08/05/2013
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