1093911828 NPI number — CANDLEWOOD FAMILY COUNSELING CENTER, INC.

Table of content: (NPI 1093911828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093911828 NPI number — CANDLEWOOD FAMILY COUNSELING CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANDLEWOOD FAMILY COUNSELING CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093911828
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83206-2306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-478-8340
Provider Business Mailing Address Fax Number:
208-478-8341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83204-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-8340
Provider Business Practice Location Address Fax Number:
208-478-8341
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DINGMAN
Authorized Official First Name:
ELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, ADMINISTRATOR
Authorized Official Telephone Number:
208-478-8340

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1093911828 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1588860308 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1912103748 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1174673305 . This is a "PRIVATE INSURANCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1831395656 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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