Basic Information
| Provider Information | |||||||||
| NPI: | 1184620791 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELMORE MEDICAL CENTER HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ELMORE MEDICAL CENTER LONG TERM CARE UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 895 N 6TH E | ||||||||
| Address2: | PO BOX 1270 | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836472207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085878401 | ||||||||
| FaxNumber: | 2085802685 | ||||||||
| Practice Location | |||||||||
| Address1: | 895 N 6TH E | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836472207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085878401 | ||||||||
| FaxNumber: | 2085802685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | SENGER | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2085878401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H5 | ID | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.