Basic Information
| Provider Information | |||||||||
| NPI: | 1003803024 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST BEC CORP DBA BURLEY CARE CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1224 | ||||||||
| Address2: | |||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833180830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086789474 | ||||||||
| FaxNumber: | 2086783727 | ||||||||
| Practice Location | |||||||||
| Address1: | 1729 MILLER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833182338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086789474 | ||||||||
| FaxNumber: | 2086783727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEDDINGTON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2086789474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 42 | ID | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1513121 | 05 | LA | MEDICAID | 804277200 | 05 | ID | MEDICAID | 01289 | 01 | ID | 314000000X | OTHER | 001989033 | 05 | NV | MEDICAID |