| Organization Name: | IDAHO DEPT OF HEALTH & WELFARE R5 CMH PSR JER |
| NPI Number: | 1669503066 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DUKE MORTON (FIELD SERVICES PROGRAM MANAGER) |
| Mailing Address: | 126 N Adams St Jerome |
| State: | ID US |
| Postal Code: | 833382331 |
| Phone Number: | 2083248862 |
| Fax Number: | |
| NPI Enumeration Date: | 03/08/2007 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rehabilitation |
| Taxonomy Definition: | |