Organization
ADOLESCENT & CHILD DEVELOPMENT CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. VANCE RAY WALKER (OWNER/EXECUTIVE DIRECTOR)
(208) 232-5622
Entity
Organization
Contact information
Practice address
151 N 3RD AVE, SUITE 110, POCATELLO, ID 83201-6331
(208) 232-5622
(208) 233-4639
Mailing address
151 N 3RD AVE, SUITE 110, POCATELLO, ID 83201-6331
(208) 232-5622
(208) 233-4639
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
261QD1600X
ID
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
261QM0801X
ID
261QM0850X
Adult Mental Health Clinic/Center
261QM0850X
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
808028200
—
ID
05
—
808257100
—
ID
05
—
808259000
—
ID
Enumeration date
06/02/2008
Last updated
04/02/2009
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