Organization
STATE OF IDAHO
Active
Parent organization
STATE HOSPITAL SOUTH
Other names
State Hospital South Group
Organization subpart
Yes
Provider details
NPI number
Legal business name
STATE HOSPITAL SOUTH
Authorized official
LORNA B COLVIN (PATIENT ACCOUNT SPECIALIST)
(208) 785-8506
Entity
Organization
Contact information
Practice address
700 E ALICE ST, BLACKFOOT, ID 83221-4925
(208) 785-8506
(208) 785-8518
Mailing address
700 E ALICE ST, PO BOX 400, BLACKFOOT, ID 83221-4925
(208) 785-8506
(208) 785-8518
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
17
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00844
BLUE CROSS
ID
05
—
1992789101
—
ID
01
—
20315
REGENCE BLUE SHIELD
ID
Enumeration date
01/03/2011
Last updated
01/03/2011
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