Provider Demographics
NPI:1154572311
Name:SOUTHERN IDAHO DIABETES EDUCATION PROGRAM
Entity type:Organization
Organization Name:SOUTHERN IDAHO DIABETES EDUCATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SIDEP COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:EVALENA
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CDE
Authorized Official - Phone:208-944-4747
Mailing Address - Street 1:113 S APPLE ST
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-5287
Mailing Address - Country:US
Mailing Address - Phone:208-886-6222
Mailing Address - Fax:208-886-2634
Practice Address - Street 1:108 NW RAIL ST
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352
Practice Address - Country:US
Practice Address - Phone:208-944-4747
Practice Address - Fax:208-886-2634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHOSHONE FAMILY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care