Basic Information
| Provider Information | |||||||||
| NPI: | 1831323047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE FAMILY SERVICES NORTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLIANCE FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 S DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082655049 | ||||||||
| FaxNumber: | 2082637515 | ||||||||
| Practice Location | |||||||||
| Address1: | 709 CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838611855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082455427 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2009 | ||||||||
| LastUpdateDate: | 05/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | LANGE | ||||||||
| AuthorizedOfficialFirstName: | TRACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2082655049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 808312800 | 05 | ID | MEDICAID |