Healthcare Provider Details

I. General information

NPI: 1063592293
Provider Name (Legal Business Name): NORTHWEST BEC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 SPRAGUE AVE
BUHL ID
83316-1827
US

IV. Provider business mailing address

PO BOX 4837
POCATELLO ID
83205-4837
US

V. Phone/Fax

Practice location:
  • Phone: 208-543-6401
  • Fax: 208-543-4221
Mailing address:
  • Phone: 208-637-0999
  • Fax: 208-637-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number27
License Number StateID

VIII. Authorized Official

Name: MISS REBECCA LOUISE ADAMSON
Title or Position: AR SPECIALIST
Credential:
Phone: 208-221-6828