Healthcare Provider Details

I. General information

NPI: 1144381344
Provider Name (Legal Business Name): SISKIYOU LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9967 N MAPLE ST
HAYDEN ID
83835-8203
US

IV. Provider business mailing address

PO BOX 2792
HAYDEN ID
83835-2792
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-9856
  • Fax:
Mailing address:
  • Phone: 208-762-9856
  • Fax: 208-762-5696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC-821
License Number StateID

VIII. Authorized Official

Name: GRAHAM CHRISTENSEN
Title or Position: MEMBER
Credential:
Phone: 208-762-9856