Provider Demographics
NPI:1285794339
Name:SOUTH CENTRAL PUBLIC HEALTH DISTRICT
Entity type:Organization
Organization Name:SOUTH CENTRAL PUBLIC HEALTH DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DISTRICT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-737-5902
Mailing Address - Street 1:1020 WASHINGTON ST N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3156
Mailing Address - Country:US
Mailing Address - Phone:208-734-5900
Mailing Address - Fax:
Practice Address - Street 1:1020 WASHINGTON ST N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3156
Practice Address - Country:US
Practice Address - Phone:208-734-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
IDPA-1046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002848800Medicaid
ID805344600Medicaid
ID805321100Medicaid
ID806204600Medicaid
ID0556324Medicaid
ID002891000Medicaid
ID1910058Medicare ID - Type Unspecified
ID002891000Medicaid