Organization
IDAHODHWBH3 PAYETTE CMH PSR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TODD L HURT M.S. (FIELD OPERATIONS MANAGER)
(208) 455-7057
Entity
Organization
Contact information
Practice address
515 16TH AVE N, PAYETTE, ID 83661-2047
(208) 642-6416
(208) 642-2829
Mailing address
515 16TH AVE N, PAYETTE, ID 83661-2047
(208) 642-6416
(208) 642-2829
Taxonomy
Speciality
Code
Description
License number
State
261QR0400X
Rehabilitation Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018824
BLUESHIELD
—
05
—
8073442
—
ID
01
—
HW348
BLUE CROSS OF IDAHO
—
Enumeration date
03/01/2007
Last updated
08/22/2020
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