=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528184595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA S. KEENE CFH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1227 W EMMY CT
-----------------------------------------------------
City | KUNA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83634-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-922-3000
-----------------------------------------------------
Fax | 208-922-3384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1227 W EMMY CT
-----------------------------------------------------
City | KUNA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83634-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-922-3000
-----------------------------------------------------
Fax | 208-922-3384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 40434
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------