=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407462906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETOSHA ASSISTED LIVING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2020
-----------------------------------------------------
Last Update Date | 09/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 243 N 300 E
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-9491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-436-3332
-----------------------------------------------------
Fax | 208-436-1289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 243 N 300 E
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-9491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-510-0283
-----------------------------------------------------
Fax | 208-436-1289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MRS. DEBORAH O COVEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-510-0283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------