Healthcare Provider Details

I. General information

NPI: 1891487997
Provider Name (Legal Business Name): LIVING LEGACY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7717 PADDOCK LN
LEWISTON ID
83501-6291
US

IV. Provider business mailing address

2320 THAIN GRADE # 1016
LEWISTON ID
83501-4115
US

V. Phone/Fax

Practice location:
  • Phone: 208-503-3113
  • Fax:
Mailing address:
  • Phone: 208-503-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN RUDOLPH
Title or Position: OWNER
Credential: DO
Phone: 208-503-3113