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General NPI Number Information
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NPI Number | 1396141305
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Entity Type | Organization
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Legal Business Name | RENEWED HORIZONS, LLC
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Dates
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Enumeration Date | 11/18/2014
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Last Update Date | 12/12/2023
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Provider Practice Location Address
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Address Line | 8252 N WAYNE DR
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City | HAYDEN
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State | ID
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Zip | 83835-5029
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Country | US
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Telephone | 208-704-8008
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Fax |
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Provider Business Mailing Address
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Address Line | 8252 N WAYNE DR
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City | HAYDEN
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State | ID
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Zip | 83835-5029
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Country | US
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Telephone | 208-704-8008
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SCOTT GORDON HANSEN
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Credential |
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Telephone | 208-704-8008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | DDA-999
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License Number State | ID
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