1881761476 NPI number — VALLEY VISTA CARE CORPORATION

Table of content: (NPI 1881761476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881761476 NPI number — VALLEY VISTA CARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY VISTA CARE CORPORATION
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:
6
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:
1881761476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST MARIES
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83861-2119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-245-4576
Provider Business Mailing Address Fax Number:
208-245-2138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3668 W. 3700 N.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DARLINGTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83255-0909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-588-2700
Provider Business Practice Location Address Fax Number:
208-588-2701
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILKS
Authorized Official First Name:
KASEY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR OF CORPORATE COMPLIANCE
Authorized Official Telephone Number:
208-245-4576

Provider Taxonomy Codes

  • Taxonomy code: 3104A0630X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 805729800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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