Organization
IDAHO DEPT OF HEALTH & WELFARE REG 7 AMH BF
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RANDY RODRIQUEZ II LCSW (PROGRAM MANAGER)
(208) 528-5700
Entity
Organization
Contact information
Practice address
720 E ALICE, BLACKFOOT, ID 83221-0129
(208) 785-5871
(208) 785-5877
Mailing address
720 E ALICE PO BOX 129, BLACKFOOT, ID 83221-0129
(208) 785-5871
(208) 785-5877
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010019479
BLUE SHIELD
ID
05
—
8073683
—
ID
01
—
HW181
BLUE CROSS
ID
Enumeration date
03/08/2007
Last updated
08/10/2010
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