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1205778172

NPI Code Detail

MEDICARE: GLENDALE GROVE SENIOR LIVING, LLC

MEDICARE: GLENDALE GROVE SENIOR LIVING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1205778172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALE GROVE SENIOR LIVING, LLC

Provider Business Mailing Address
First Line	:	1675 E RIVERSIDE DR STE 150
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-7584
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1675 E RIVERSIDE DR STE 150
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-7584
Country	:	US
Telephone Number	:	208-401-1400
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	AMBER TUELLER
Credential	:
Telephone Number	:	208-207-2726

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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Directions to “GLENDALE GROVE SENIOR LIVING, LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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