Organization
HUMAN SUPPORTS OF IDAHO
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ALITA RUBY (ADMINISTRATEIVE SERVICES MANAGER)
(208) 454-8389
Entity
Organization
Contact information
Practice address
4477 W EMERALD ST, STE C-100, BOISE, ID 83706-2000
(208) 454-8389
(208) 454-8404
Mailing address
PO BOX 820, CALDWELL, ID 83606-0820
(208) 454-8389
(208) 454-8404
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
—
ID
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20002419
MEDICARE PTAN
ID
Enumeration date
03/26/2013
Last updated
10/13/2022
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