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General NPI Number Information
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NPI Number | 1508650060
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Entity Type | Organization
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Legal Business Name | COMMUNITY LIVING OF IDAHO LLC
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Dates
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Enumeration Date | 04/08/2025
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 3424 STARLIGHT AVE
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City | CALDWELL
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State | ID
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Zip | 83605-6647
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Country | US
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Telephone | 208-906-4249
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Fax |
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Provider Business Mailing Address
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Address Line | 3424 STARLIGHT AVE
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City | CALDWELL
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State | ID
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Zip | 83605-6647
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Country | US
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Telephone | 208-906-4249
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PAUL DANIEL FAUTH
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Credential |
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Telephone | 208-906-4249
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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