Organization
IDAHO DEPT OF HEALTH & WELFARE ITP REG. 1
Active
Organization
IDAHO DEPT OF HEALTH & WELFARE ITP REG. 1
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MARY J JONES B.U.S. (PROGRAM MANAGER)
(208) 334-5523
Entity
Organization
Contact information
Practice address
2195 IRONWOOD CT, COEUR D ALENE, ID 83814-2628
(208) 769-1409
(208) 769-1430
Mailing address
2195 IRONWOOD CT, COEUR D ALENE, ID 83814-2628
(208) 769-1409
(208) 769-1430
Taxonomy
Speciality
Code
Description
License number
State
251300000X
Local Education Agency (LEA)
—
—
252Y00000X
Early Intervention Provider Agency
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010018372
BLUE SHIELD
ID
05
—
0028409
—
ID
01
—
HW249
BLUE CROSS OF IDAHO
ID
Enumeration date
02/05/2007
Last updated
08/05/2013
Update your record
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