Organization
LATINO STAND UP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROMAN CRUZ (OWNER)
(208) 313-0711
Entity
Organization
Contact information
Practice address
1420 E 17TH ST, SUITE A, IDAHO FALLS, ID 83404-6283
(208) 313-0711
Mailing address
1420 E 17TH ST, SUITE A, IDAHO FALLS, ID 83404-6283
(208) 313-0711
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
251S00000X
Community/Behavioral Health Agency
—
—
Other
Enumeration date
12/31/2012
Last updated
12/31/2012
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