State of Idaho

NPI #1962755868 in Hayden, Idaho

Provider Information

NPI Number: 1962755868
Entity Type: Organization
Organization Name: State of Idaho
Primary Specialty: Intermediate Care Facility, Intellectual Disabilities
Enumeration Date: Oct 17, 2012
Last Updated: Oct 17, 2012

Practice Location

Address: 1182 WEST KYLER AVE
City: Hayden
State: Idaho
ZIP Code: 83835
Phone: (208) 762-0244

Authorized Official

Name: SUSAN BROETJE
Title: ADMINISTRATOR
Phone: (208) 697-0625

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Intermediate Care Facility, Intellectual Disabilities	315P00000X	Primary

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