MEDICARE: GRACE AT FAIRVIEW LAKES 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790309045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE AT FAIRVIEW LAKES LLC

Provider Business Mailing Address
First Line	:	890 N COLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8638
Country	:	US
Telephone Number	:	208-884-8080
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 N LAKES PL
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5939
Country	:	US
Telephone Number	:	208-844-8080
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LINDA HINES
Credential	:
Telephone Number	:	208-867-1001

Provider Enumeration Date	:	06/02/2020
Last Update Date	:	06/02/2020

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Directions to “GRACE AT FAIRVIEW LAKES LLC ” Practice Location

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