Organization
IDAHO DEPT OF HEALTH & WELFARE R5 AMH CL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DUKE MORTON (FIELD SERVICES PROGRAM MANAGER)
(208) 736-2177
Entity
Organization
Contact information
Practice address
823 HARRISON ST, TWIN FALLS, ID 83301-3925
(208) 736-2177
Mailing address
823 HARRISON ST, TWIN FALLS, ID 83301-3925
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010025421
BLUESHIELD
ID
05
—
0028319
—
ID
01
—
HW173
BLUE CROSS
ID
Enumeration date
03/08/2007
Last updated
08/22/2020
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