1215391297 NPI number — PEER RECOVERY SUPPORTS OF IDAHO

Table of content: (NPI 1215391297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215391297 NPI number — PEER RECOVERY SUPPORTS OF IDAHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEER RECOVERY SUPPORTS OF IDAHO
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:
1215391297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
963 S ORCHARD ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83705-1939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-352-0535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
963 S ORCHARD ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705-1939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-352-0535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BIGGINS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
208-352-0535

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com