=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073864815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHOINHOMECARE., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2012
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 E FAIRVIEW AVE SUITE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-8048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-288-2200
-----------------------------------------------------
Fax | 208-288-2299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 845 E FAIRVIEW AVE SUITE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-8048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-288-2200
-----------------------------------------------------
Fax | 208-288-2299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FRANCO GELSOMINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-288-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------