Provider Demographics
| NPI: | 1487076048 |
|---|---|
| Name: | DIRNE HEALTH CENTERS, INC |
| Entity type: | Organization |
| Organization Name: | DIRNE HEALTH CENTERS, INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | MICHAEL |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BAKER |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 208-620-5200 |
| Mailing Address - Street 1: | PO BOX 1387 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | HAYDEN |
| Mailing Address - State: | ID |
| Mailing Address - Zip Code: | 83835-1387 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 208-620-5200 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 740 MCKINLEY AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | KELLOGG |
| Practice Address - State: | ID |
| Practice Address - Zip Code: | 83837-2693 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 087-831-2672 |
| Practice Address - Fax: | 844-807-3782 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | DIRNE HEALTH CENTERS INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2014-01-15 |
| Last Update Date: | 2023-08-24 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 101YS0200X, 104100000X, 1041C0700X, 122300000X, 207Q00000X, 207R00000X, 363A00000X, 363L00000X, 363LF0000X | ||
| ID | 261QF0400X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 101YS0200X | Behavioral Health & Social Service Providers | Counselor | School | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| ID | 1378465 | Other | MEDICARE PART B PTAN 1378465 |
| ID | 131856 | Medicare Oscar/Certification |
