Healthcare Provider Details

I. General information

NPI: 1689672495
Provider Name (Legal Business Name): LOST RIVERS DISTRICT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 HIGHLAND DR
ARCO ID
83213-9771
US

IV. Provider business mailing address

PO BOX 145
ARCO ID
83213-0145
US

V. Phone/Fax

Practice location:
  • Phone: 208-527-8206
  • Fax: 208-527-3430
Mailing address:
  • Phone: 208-527-8206
  • Fax: 208-527-3430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberH45
License Number StateID

VIII. Authorized Official

Name: MR. KIM DAHLMAN
Title or Position: CEO
Credential:
Phone: 208-527-8206