Provider Demographics
NPI:1730997958
Name:GROW DEVELOPMENTAL DISABILITY SOLUTIONS IDAHO
Entity type:Organization
Organization Name:GROW DEVELOPMENTAL DISABILITY SOLUTIONS IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIBERTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-882-2525
Mailing Address - Street 1:205 STOCKHAM BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5285
Mailing Address - Country:US
Mailing Address - Phone:503-882-2525
Mailing Address - Fax:
Practice Address - Street 1:205 STOCKHAM BLVD STE D
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5285
Practice Address - Country:US
Practice Address - Phone:503-882-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care