Provider Demographics
NPI:1073661328
Name:DME HEALTH MANAGEMENT GROUP LLC
Entity type:Organization
Organization Name:DME HEALTH MANAGEMENT GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MAJORITY MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-7730
Mailing Address - Street 1:P.O. BOX 1641
Mailing Address - Street 2:460 MAIN AVE. SOUTH SUITE C
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-734-7730
Mailing Address - Fax:208-735-8176
Practice Address - Street 1:460 MAIN AVE SOUTH
Practice Address - Street 2:SUITE C
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-734-7730
Practice Address - Fax:208-735-8176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806769900Medicaid
ID806815900Medicaid
ID806875000Medicaid
ID806857800Medicaid