Provider Demographics
NPI:1649539495
Name:LATINO STAND UP IDAHO LLC
Entity type:Organization
Organization Name:LATINO STAND UP IDAHO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:T
Authorized Official - Last Name:HORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-346-2222
Mailing Address - Street 1:1680 WOODRUFF PARK
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3330
Mailing Address - Country:US
Mailing Address - Phone:208-346-2222
Mailing Address - Fax:
Practice Address - Street 1:1680 WOODRUFF PARK
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3330
Practice Address - Country:US
Practice Address - Phone:208-346-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X, 261QM0850X, 261QM0855X, 261QR0405X, 261QM0801X
ID163W00000X, 2084P0804X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty