Organization
IDAHO DEPT OF HEALTH & WELFARE REG II CMH 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) 476-9516
Mailing address
PO BOX 712, OROFINO, ID 83544-0712
(208) 476-7703
(208) 476-3636
Taxonomy
Speciality
Code
Description
License number
State
261QR0400X
Rehabilitation Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018450
BLUE SHIELD
—
05
—
8073497
—
ID
01
—
HW140
BLUE CROSS OF IDAHO
—
Enumeration date
03/05/2007
Last updated
08/22/2020
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