Healthcare Provider Details

I. General information

NPI: 1396682894
Provider Name (Legal Business Name): 10250 W SMOKE RANCH DRIVE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10250 W SMOKE RANCH DR
BOISE ID
83709-1467
US

IV. Provider business mailing address

10250 W SMOKE RANCH DR
BOISE ID
83709-1467
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-2900
  • Fax:
Mailing address:
  • Phone: 207-540-3810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MATT GAGNON
Title or Position: DIRECTOR OF BUSINESS OPTIMIZATION
Credential: GAGNON
Phone: 207-540-3810