Organization Name: | STATE OF IDAHO |
NPI Number: | 1811028319 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | EDWARD A. MARUGG (DIRECTOR) |
Mailing Address: | 1901 Alvin Ricken Dr Pocatello |
State: | ID US |
Postal Code: | 832012727 |
Phone Number: | 2082395242 |
Fax Number: | 2084789297 |
NPI Enumeration Date: | 03/08/2007 |
NPI Last Update Date: | 07/10/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 251K00000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Agencies |
Taxonomy Classification: | Public Health or Welfare |
Taxonomy Specialization: | |
Taxonomy Definition: |