Healthcare Provider Details

I. General information

NPI: 1932520640
Provider Name (Legal Business Name): KEY STONE HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 N FISHER PARK WAY
EAGLE ID
83616-4796
US

IV. Provider business mailing address

21 N FISHER PARK WAY
EAGLE ID
83616-4796
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-0670
  • Fax: 208-549-7880
Mailing address:
  • Phone: 208-514-0670
  • Fax: 208-549-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP-1166A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LEONARD R JENSEN
Title or Position: PRESIDENT
Credential: FNP
Phone: 503-523-6404