Provider Demographics
NPI:1871915694
Name:CLUB INC
Entity type:Organization
Organization Name:CLUB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LNSW
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-241-1377
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 S WOODRUFF
Practice Address - Street 2:SUITE 6
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-529-4673
Practice Address - Fax:208-529-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-30202261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)