Basic Information
| Provider Information | |||||||||
| NPI: | 1760060933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR BEHAVIORAL HEALTH IDAHO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 SPRING VALLEY ROAD | ||||||||
| Address2: | SUITE 600 EAST | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143656100 | ||||||||
| FaxNumber: | 2143656150 | ||||||||
| Practice Location | |||||||||
| Address1: | 2426 N MERRITT CREEK LOOP STE B | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082965385 | ||||||||
| FaxNumber: | 2082965387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2021 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | HIGHAM | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2143656100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.