Basic Information
Provider Information | |||||||||
NPI: | 1063966638 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BOISE WEST OF CASCADIA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARBOR VALLEY OF CASCADIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 408 S. EAGLE ROAD | ||||||||
Address2: | SUITE 205 | ||||||||
City: | EAGLE | ||||||||
State: | ID | ||||||||
PostalCode: | 83616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9494166633 | ||||||||
FaxNumber: | 8443623862 | ||||||||
Practice Location | |||||||||
Address1: | 8211 USTICK ROAD | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837045756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088866401 | ||||||||
FaxNumber: | 8443623862 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2016 | ||||||||
LastUpdateDate: | 01/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAFORTE | ||||||||
AuthorizedOfficialFirstName: | STEVE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL AND DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2063514535 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.