=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528707742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO IN HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2022
-----------------------------------------------------
Last Update Date | 06/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 ORCHARD CIR
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-4656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-557-1152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3456 E 17TH ST STE 285
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-5069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-941-1543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PETE BLUE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-881-4821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------