Healthcare Provider Details

I. General information

NPI: 1245757509
Provider Name (Legal Business Name): CANYONS RETIREMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 CHENEY DR W
TWIN FALLS ID
83301-1203
US

IV. Provider business mailing address

4881 CLOVER DELL RD
CHUBBUCK ID
83202-1805
US

V. Phone/Fax

Practice location:
  • Phone: 208-358-9624
  • Fax: 775-307-4049
Mailing address:
  • Phone: 208-252-5902
  • Fax: 775-307-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: TROY V BELL
Title or Position: PRESIDENT/CEO
Credential:
Phone: 208-221-0481