Provider Demographics
NPI:1720845316
Name:IDAHO VOICE AND SWALLOW CENTER LLC
Entity type:Organization
Organization Name:IDAHO VOICE AND SWALLOW CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDES
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:402-318-4783
Mailing Address - Street 1:875 S VANGUARD WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8542
Mailing Address - Country:US
Mailing Address - Phone:208-298-9949
Mailing Address - Fax:208-274-4474
Practice Address - Street 1:875 S VANGUARD WAY STE 200
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8542
Practice Address - Country:US
Practice Address - Phone:208-298-9949
Practice Address - Fax:208-274-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-29
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty