Healthcare Provider Details

I. General information

NPI: 1770599409
Provider Name (Legal Business Name): VALLEY VISTA CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ELM ST
ST MARIES ID
83861-2119
US

IV. Provider business mailing address

820 ELM ST
ST MARIES ID
83861-2119
US

V. Phone/Fax

Practice location:
  • Phone: 208-245-4576
  • Fax: 208-245-2138
Mailing address:
  • Phone: 208-245-4576
  • Fax: 208-245-2138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number23
License Number StateID

VIII. Authorized Official

Name: KASEY D WILKS
Title or Position: DIRECTOR OF CORPORATE COMPLIANCE
Credential:
Phone: 208-245-4576