| State Of Idaho | |
|
1720 N Westgate Dr Boise ID 83704-7164 | |
| (208) 334-0824 | |
| Not Available |
| Full Name | State Of Idaho |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1720 N Westgate Dr, Boise, Idaho |
| Authorized Official Name and Position | Wayne Nubile (CLINICAL SUPERVISOR) |
| Authorized Official Contact | 2083340824 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| State Of Idaho 2322 W State St Boise ID 83702-3161 Ph: (208) 334-0824 | State Of Idaho 1720 N Westgate Dr Boise ID 83704-7164 Ph: (208) 334-0824 |
| NPI Number | 1790131027 |
|---|---|
| Provider Enumeration Date | 05/05/2016 |
| Last Update Date | 05/05/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790131027 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | LCPC-5579 (Idaho) | Primary |
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