Individual
ANDREA LOBAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
5049 FOX CREEK HOLLOW, VICTOR, ID 83455-0000
(208) 201-3467
Mailing address
5049 FOX CREEK HOLLOW, VICTOR, ID 83455-0000
(208) 201-3467
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
127612300
MEDICAID PROVIDER NUMBER
WY
Enumeration date
08/22/2014
Last updated
08/22/2014
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