=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396682894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 10250 W SMOKE RANCH DRIVE OPCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2026
-----------------------------------------------------
Last Update Date | 05/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10250 W SMOKE RANCH DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-322-2900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10250 W SMOKE RANCH DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-540-3810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF BUSINESS OPTIMIZATION
-----------------------------------------------------
Name | MATT GAGNON
-----------------------------------------------------
Credential | GAGNON
-----------------------------------------------------
Telephone | 207-540-3810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------