Organization
IDAHO DEPT OF HEALTH & WELFARE REG 2 AMH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VICKI MALONE (PROGRAM MANAGER)
(208) 799-4440
Entity
Organization
Contact information
Practice address
216 S C ST, GRANGEVILLE, ID 83530-1342
(208) 983-2300
Mailing address
PO BOX 548, GRANGEVILLE, ID 83530-0548
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018440
BLUE SHIELD
ID
01
—
HW264
BLUE CROSS
ID
Enumeration date
02/23/2011
Last updated
02/23/2011
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