Basic Information
Provider Information | |||||||||
NPI: | 1861533176 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | A FULL LIFE HOME HEALTH LEWISTON INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 102 11TH ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835011936 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087468881 | ||||||||
FaxNumber: | 2087465694 | ||||||||
Practice Location | |||||||||
Address1: | 102 11TH ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835011936 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087468881 | ||||||||
FaxNumber: | 2087465694 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2007 | ||||||||
LastUpdateDate: | 09/17/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRACKETT | ||||||||
AuthorizedOfficialFirstName: | HOPE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2087468881 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   | ID | Y |   | Agencies | Home Health |   |
No ID Information.