IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME
Complete NPI Record 1720118904
Clinic/Center - Mental Health (Including Community Mental Health Center) in Mountain Home, ID
NPI Status: Active since March 06, 2007
Contact Information
2420 AMERICAN LEGION BLVD
MOUNTAIN HOME, ID
ZIP 83647
Phone: (208) 587-9061
Fax: (208) 587-5024
Complete NPI Dataset
This directory record outlines the complete schema field listings, logged data values, and structural definitions for IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME (NPI: 1720118904), practicing as a certified clinic/center specialist with primary operations located in Mountain Home, ID. The dataset listed below details the current information logged inside the National Plan and Provider Enumeration System (NPPES) registry database for this specific individual assignment. Please use the integrated filtering tools directly below to separate properties by functional clinical categories, perform live keyword lookups, or jump immediately to a single tracking attribute line item.
Registry File Document Utilities
- NPI: 1720118904
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: UNAVAIL
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider First Line Business Mailing Address: 1720 WESTGATE DR
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Second Line Business Mailing Address: SUITE B-1
- The second line mailing address of the provider being identified. This data element may contain the same information as "Provider second line location address".
- Provider Business Mailing Address City Name: BOISE
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: ID
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 837047164
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 2083340894
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 2083340804
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 2420 AMERICAN LEGION BLVD
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: MOUNTAIN HOME
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: ID
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 836473146
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 2085879061
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 2085875024
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: WESTCOTT
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: GINA
- The first name of the authorized official.
- Authorized Official Title or Position: PROGRAM MANAGER
- The title or position of the authorized official.
- Authorized Official Telephone Number: 2083340969
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 261QM0801X
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: Y
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: 8073418
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 05
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: ID
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 2: 000010018973
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 01
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 2: BLUE SHIELD
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 3: HW280
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 3: 01
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 3: BLUE CROSS OF IDAHO
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Is Organization Subpart: N
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Authorized Official Credential Text: M.A.
- The professional credential(s) of the authorized official listed on the provider's NPI record. Examples include MD (Doctor of Medicine), DO (Doctor of Osteopathy), RN (Registered Nurse), DDS (Doctor of Dental Surgery), PhD, or other recognized designations that reflect the official's qualifications.
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