Provider Demographics
NPI:1902937618
Name:COUNTY OF SHOSHONE JOINT SCHOOL DISTRICT 391
Entity Type:Organization
Organization Name:COUNTY OF SHOSHONE JOINT SCHOOL DISTRICT 391
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEMS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:LEVESQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-922-3093
Mailing Address - Street 1:176 E CALDERWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9097
Mailing Address - Country:US
Mailing Address - Phone:208-922-3093
Mailing Address - Fax:208-922-9351
Practice Address - Street 1:800 BUNKER AVE # 122
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2209
Practice Address - Country:US
Practice Address - Phone:208-783-2870
Practice Address - Fax:208-752-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805135500Medicaid