Basic Information
| Provider Information | |||||||||
| NPI: | 1770009680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYON WEST OF CASCADIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 S EAGLE RD STE 205 | ||||||||
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| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836166079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084019600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2814 S INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836055925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084590808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAFORTE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2063514535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | ID | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.