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General NPI Number Information
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NPI Number | 1235675380
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Entity Type | Organization
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Legal Business Name | PETERSON PLACE AFH INC
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Dates
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Enumeration Date | 01/13/2017
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Last Update Date | 01/13/2017
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Provider Practice Location Address
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Address Line | 1027 E HONEYSUCKLE AVE
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City | HAYDEN
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State | ID
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Zip | 83835-9291
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Country | US
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Telephone | 208-719-9405
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Fax | 208-719-9406
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Provider Business Mailing Address
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Address Line | 1027 E HONEYSUCKLE AVE
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City | HAYDEN
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State | ID
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Zip | 83835-9291
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Country | US
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Telephone | 208-719-9405
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Fax | 208-719-9406
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | HEIDI A PETERSON
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Credential |
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Telephone | 509-979-2773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | RC1126
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License Number State | ID
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