Organization
IDAHO DEPT OF HEALTH & WELFARE REG. II AMH OROFINO
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VICKI R. MALONE MSW (PROGRAM MANAGER)
(208) 799-4440
Entity
Organization
Contact information
Practice address
416 JOHNSON AVE, OROFINO, ID 83544-9516
(208) 476-7703
(208) 476-3636
Mailing address
PO BOX 712, OROFINO, ID 83544-0712
(208) 476-7703
(208) 476-3636
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
—
000010018440
BLUE SHIELD
—
05
—
8073805
—
ID
01
—
HW264
BLUE CROSS OF IDAHO
—
Enumeration date
03/01/2007
Last updated
08/22/2020
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