Organization
IDAHO DEPT OF HEALTH & WELFARE REG 2 CMH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VICKI MALONE (PROGRAM MANAGER)
(208) 799-4440
Entity
Organization
Contact information
Practice address
1350 TROY HIGHWAY, MOSCOW, ID 83843-3995
(208) 882-0562
Mailing address
1350 TROY HIGHWAY, MOSCOW, ID 83843-3995
(208) 882-0562
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018450
BLUE SHIELD
ID
01
—
HW140
BLUE CROSS
ID
Enumeration date
02/17/2011
Last updated
02/17/2011
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