Basic Information
| Provider Information | |||||||||
| NPI: | 1306322953 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENNETT HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BENNETT HILLS REHABILITATION AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 MONTANA ST | ||||||||
| Address2: | |||||||||
| City: | GOODING | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833301856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089345601 | ||||||||
| FaxNumber: | 2089348154 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 MONTANA ST | ||||||||
| Address2: | |||||||||
| City: | GOODING | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833301856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089345601 | ||||||||
| FaxNumber: | 2089348154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2018 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNAM | ||||||||
| AuthorizedOfficialFirstName: | SOON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9495401249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.