Healthcare Provider Details

I. General information

NPI: 1518115773
Provider Name (Legal Business Name): CHAROLAIS CARE IV, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 E 4TH ST
SHOSHONE ID
83352-5380
US

IV. Provider business mailing address

511 E 4TH ST
SHOSHONE ID
83352-5380
US

V. Phone/Fax

Practice location:
  • Phone: 208-886-2228
  • Fax:
Mailing address:
  • Phone: 208-886-2226
  • Fax: 208-886-2549

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: JIM EVERTON
Title or Position: CEO
Credential:
Phone: 208-233-4673