Basic Information
| Provider Information | |||||||||
| NPI: | 1790076362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTERNATIVE COMMUNITY ENRICHMENT SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ACES COMMUNITY SERVICES, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838143310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082922188 | ||||||||
| FaxNumber: | 2082922189 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W COLLEGE AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838611822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454363 | ||||||||
| FaxNumber: | 2082454349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2011 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2082922188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ID | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 808280600 | 05 | ID | MEDICAID | 808328100 | 05 | ID | MEDICAID | 808367901 | 05 | ID | MEDICAID | 808328200 | 05 | ID | MEDICAID | 808367900 | 05 | ID | MEDICAID | 806388100 | 05 | ID | MEDICAID |