1285624064 NPI number — DIVISION OF VETERANS SERVICES

Table of content: (NPI 1285624064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285624064 NPI number — DIVISION OF VETERANS SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVISION OF VETERANS SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IDAHO STATE VETERANS HOME - POCATELLO
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285624064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1957 ALVIN RICKEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-2727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-236-6340
Provider Business Mailing Address Fax Number:
208-236-6343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1957 ALVIN RICKEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-236-6340
Provider Business Practice Location Address Fax Number:
208-236-6343
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRASUELL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-236-6340

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  92 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1307126 . This is a "NCPDP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 995HP . This is a "PHARMACY LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 92 . This is a "NURSING FACILITY LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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