Provider Demographics
NPI:1962755868
Name:STATE OF IDAHO
Entity type:Organization
Organization Name:STATE OF IDAHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROETJE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-697-0625
Mailing Address - Street 1:1660 11TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-5000
Mailing Address - Country:US
Mailing Address - Phone:208-442-2812
Mailing Address - Fax:208-467-5978
Practice Address - Street 1:1182 WEST KYLER AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-762-0244
Practice Address - Fax:208-762-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID81315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities