Provider Demographics
NPI:1871935064
Name:COMMUNITY CONNECTIONS NORTH, INC.
Entity type:Organization
Organization Name:COMMUNITY CONNECTIONS NORTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEIGHBORS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-377-9814
Mailing Address - Street 1:1675 S MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2531
Mailing Address - Country:US
Mailing Address - Phone:208-377-9814
Mailing Address - Fax:
Practice Address - Street 1:1230 N NORTHWOOD CENTER CT
Practice Address - Street 2:SUITE A
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4941
Practice Address - Country:US
Practice Address - Phone:208-664-1065
Practice Address - Fax:208-765-2258
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CONNECTIONS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDDA-3922251C00000X
IDRHA-3904320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0001084Medicaid