Healthcare Provider Details

I. General information

NPI: 1306322953
Provider Name (Legal Business Name): BENNETT HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 MONTANA ST
GOODING ID
83330-1856
US

IV. Provider business mailing address

1220 MONTANA ST
GOODING ID
83330-1856
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-5601
  • Fax: 208-934-8154
Mailing address:
  • Phone: 208-934-5601
  • Fax: 208-934-8154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249