Healthcare Provider Details

I. General information

NPI: 1952940041
Provider Name (Legal Business Name): BLAIR LEGACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 N STEELHEAD WAY STE 180
BOISE ID
83704-8388
US

IV. Provider business mailing address

554 N STEELHEAD WAY STE 180
BOISE ID
83704-8388
US

V. Phone/Fax

Practice location:
  • Phone: 208-515-6522
  • Fax:
Mailing address:
  • Phone: 208-515-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: SHAYLA R MONNIER
Title or Position: OWNER
Credential: RN
Phone: 208-972-0018