Provider Demographics
NPI:1932454642
Name:ADOLPHO ENTERPRISE LLC.
Entity type:Organization
Organization Name:ADOLPHO ENTERPRISE LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ADOLPHO
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MBA, PSR
Authorized Official - Phone:435-553-9822
Mailing Address - Street 1:3649 N LAKEHARBOR LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-6913
Mailing Address - Country:US
Mailing Address - Phone:435-553-9822
Mailing Address - Fax:208-853-5377
Practice Address - Street 1:3649 N LAKEHARBOR LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-6913
Practice Address - Country:US
Practice Address - Phone:435-553-9822
Practice Address - Fax:208-853-5377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADOLPHO ENTERPRISE LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-18
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1932454642Medicaid