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General NPI Number Information
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NPI Number | 1356008825
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Entity Type | Organization
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Legal Business Name | SAGE CREST RETIREMENT VILLAGE LTD
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Dates
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Enumeration Date | 11/19/2021
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Last Update Date | 11/19/2021
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Provider Practice Location Address
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Address Line | 500 CREST LINE DR
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City | BUHL
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State | ID
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Zip | 83316
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Country | US
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Telephone | 208-536-3602
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 387
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City | BUHL
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State | ID
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Zip | 83316-0387
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Country | US
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Telephone | 208-536-3602
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | VIRGINIA KOEHN
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Credential | RN
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Telephone | 208-536-3602
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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 |
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License Number State |
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