Basic Information
| Provider Information | |||||||||
| NPI: | 1780981902 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KOOTENAI MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADULT DAY PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086662000 | ||||||||
| FaxNumber: | 2086663963 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086662000 | ||||||||
| FaxNumber: | 2086663963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2011 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NESS | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2086662000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KOOTENAI MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | 42 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | M8056472 | 05 | ID | MEDICAID |