Basic Information
| Provider Information | |||||||||
| NPI: | 1174767180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTERNATIVE COMMUNITY ENRICHMENT SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ACES COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 N 4TH STREET | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082922188 | ||||||||
| FaxNumber: | 2082922189 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 BANK STREET | ||||||||
| Address2: | |||||||||
| City: | WALLACE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085560960 | ||||||||
| FaxNumber: | 2087521048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 03/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2082922188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 104100000X | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1669672689 | 05 | ID | MEDICAID | 1215055868 | 05 | ID | MEDICAID | 1912127648 | 05 | ID | MEDICAID | 1093935728 | 05 | ID | MEDICAID | 1477629996 | 05 | ID | MEDICAID | 1548414519 | 05 | ID | MEDICAID | 1295956266 | 05 | ID | MEDICAID | 1689689085 | 05 | ID | MEDICAID |