Organization
IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH CM CDA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CORA JO GUSSENHOVEN (PROGRAM MANAGER)
(208) 769-1406
Entity
Organization
Contact information
Practice address
2195 IRONWOOD CT, COEUR D ALENE, ID 83814-2628
(208) 769-1406
(208) 769-1430
Mailing address
2195 IRONWOOD CT, COEUR D ALENE, ID 83814-2628
(208) 769-1406
(208) 769-1430
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0028455
—
ID
Enumeration date
02/27/2007
Last updated
08/22/2020
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