Organization
IDAHO DEPT OF HEALTH &WELFARE REG 6 CMH PSR P
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RITCHIE WEERS (CLINICAL SUPERVISOR)
(208) 234-7900
Entity
Organization
Contact information
Practice address
421 MEMORIAL DR, POCATELLO, ID 83201-4008
(208) 234-7900
(208) 236-6328
Mailing address
421 MEMORIAL DR, POCATELLO, ID 83201-4008
(208) 234-7900
(208) 236-6328
Taxonomy
Speciality
Code
Description
License number
State
261QR0400X
Rehabilitation Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010019402
BLUE SHIELD
ID
05
—
0028412
—
ID
01
—
HW157
BLUE CROSS OF IDAHO
ID
Enumeration date
03/12/2007
Last updated
10/22/2010
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