=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306459599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COEUR D ALENE HOMES PHASE II
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2020
-----------------------------------------------------
Last Update Date | 04/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 624 W HARRISON AVE
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-5286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-664-8119
-----------------------------------------------------
Fax | 208-292-2551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 624 W HARRISON AVE
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-5286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-664-8119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TIFFANY PETTIT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-664-8119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------