Organization
IDAHO DEPT OF HEALTH & WELFARE REGION 7 CMH PSR IF
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MELISSA M BEAN MA (PROGRAM MANAGER)
(208) 528-5706
Entity
Organization
Contact information
Practice address
150 SHOUP AVE, SUITE 17, IDAHO FALLS, ID 83402-3657
(208) 528-5700
(208) 528-5747
Mailing address
150 SHOUP AVE, SUITE 17, IDAHO FALLS, ID 83402-3657
(208) 528-5700
(208) 528-5747
Taxonomy
Speciality
Code
Description
License number
State
261QR0400X
Rehabilitation Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010019677
BLUE SHIELD
—
05
—
0028413
—
ID
01
—
HW157
BLUE CROSS OF IDAHO
—
Enumeration date
02/27/2007
Last updated
08/22/2020
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