Organization
IDAHO DEPT OF HEALTH & WELFARE REG 6 CMH BF C
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ED AXFORD (PROGRAM MANAGER)
(208) 234-7900
Entity
Organization
Contact information
Practice address
701 E ALICE, BLACKFOOT, ID 83221-0129
(208) 785-5826
(208) 785-1003
Mailing address
PO BOX 129, BLACKFOOT, ID 83221-0129
(208) 785-5826
(208) 785-1003
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
—
000010019402
BLUE SHIELD
ID
05
—
8073650
—
ID
01
—
HW157
BLUE CROSS
ID
Enumeration date
03/09/2007
Last updated
08/22/2020
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