1497143747 NPI number — ADVANCED CARE NORTHWEST LLC

Table of content: (NPI 1497143747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497143747 NPI number — ADVANCED CARE NORTHWEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED CARE NORTHWEST LLC
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:
Provider Other Organization Name Type Code:
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:
1497143747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1869
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNERS FERRY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83805-1869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-263-3225
Provider Business Mailing Address Fax Number:
208-267-2003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 HIGHWAY 2
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-3225
Provider Business Practice Location Address Fax Number:
208-267-2003
Provider Enumeration Date:
01/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BALDWIN
Authorized Official First Name:
AMY
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
MEMBER/ MANGER
Authorized Official Telephone Number:
208-263-3225

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A0001748 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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