Organization
IDAHO DEPT OF HEALTH & WELFARE REG II AMH LEW. CLINIC
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
1118 F ST, LEWISTON, ID 83501-1930
(208) 799-4440
(208) 799-5171
Mailing address
1118 F ST, DRAWER B, LEWISTON, ID 83501-1930
(208) 799-4440
(208) 799-5171
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018440
BLUE SHIELD
—
05
—
0028329
—
ID
01
—
HW264
BLUE CROSS OF IDAHO
—
Enumeration date
03/02/2007
Last updated
08/22/2020
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