Healthcare Provider Details

I. General information

NPI: 1750309795
Provider Name (Legal Business Name): SHOSHONE REHAB AND LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 EAST 4TH STREET
SHOSHONE ID
83352
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: 208-886-2549
Mailing address:
  • Phone: 208-886-2228
  • Fax: 208-886-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number20
License Number StateID

VIII. Authorized Official

Name: MRS. SHARON RAE SULLIVAN
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 208-886-2228