Basic Information
Provider Information | |||||||||
NPI: | 1124335476 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LINCOLN COUNTY CARE CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 275 S 5TH AVE | ||||||||
Address2: | LOWER LEVEL | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832016400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082334673 | ||||||||
FaxNumber: | 2082334750 | ||||||||
Practice Location | |||||||||
Address1: | 511 E 4TH ST | ||||||||
Address2: |   | ||||||||
City: | SHOSHONE | ||||||||
State: | ID | ||||||||
PostalCode: | 833525380 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088862228 | ||||||||
FaxNumber: | 2088862549 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2010 | ||||||||
LastUpdateDate: | 09/08/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EVERTON | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2082334673 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 20 | ID | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.