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460 Main Ave South Suite C Twin Falls ID 83301 | |
| (208) 734-7730 | |
| (208) 735-8176 |
| Full Name | |
|---|---|
| Speciality | Case Management |
| Location | 460 Main Ave South, Twin Falls, Idaho |
| Authorized Official Name and Position | Mark Moreno (MAJORITY MEMBER) |
| Authorized Official Contact | 2087347730 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
P.o. Box 1641 460 Main Ave. South Suite C Twin Falls ID 83301 Ph: (208) 734-7730 | 460 Main Ave South Suite C Twin Falls ID 83301 Ph: (208) 734-7730 |
| NPI Number | 1073661328 |
|---|---|
| Provider Enumeration Date | 01/05/2007 |
| Last Update Date | 09/16/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1073661328 | NPI | - | NPPES |
| 806769900 | Medicaid | ID | |
| 806815900 | Medicaid | ID | |
| 806875000 | Medicaid | ID | |
| 806857800 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101Y00000X | Counselor | (* (Not Available)) | Secondary |
| 251B00000X | Case Management | (* (Not Available)) | Primary |
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