Healthcare Provider Details

I. General information

NPI: 1326908765
Provider Name (Legal Business Name): LIFEBRIDGE SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3295 W ELDER ST STE 201
BOISE ID
83705-4762
US

IV. Provider business mailing address

3295 W ELDER ST STE 201
BOISE ID
83705-4762
US

V. Phone/Fax

Practice location:
  • Phone: 208-606-2055
  • Fax:
Mailing address:
  • Phone: 208-606-2055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CLAIRE KIOTA
Title or Position: CEO
Credential:
Phone: 208-801-1123