Organization
SOUTHEASTERN IDAHO DEVELOPMENTAL CENTER, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JIM P. MCCOY (OWNER DIRECTOR)
(208) 782-1301
Entity
Organization
Contact information
Practice address
765 W JUDICIAL ST, BLACKFOOT, ID 83221-2036
(208) 782-1301
(208) 782-3627
Mailing address
PO BOX 701, BLACKFOOT, ID 83221-0701
(208) 782-1301
(208) 782-3627
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8073845
—
ID
Enumeration date
04/16/2008
Last updated
04/16/2008
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