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General NPI Number Information
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NPI Number | 1609012277
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Entity Type | Organization
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Legal Business Name | LIVING SPRING RESIDENTIAL CARE
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Dates
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Enumeration Date | 01/01/2009
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Last Update Date | 01/01/2009
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Provider Practice Location Address
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Address Line | 1050 HEMLOCK DR
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City | LEWISTON
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State | ID
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Zip | 83501-5434
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Country | US
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Telephone | 208-743-2685
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Fax |
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Provider Business Mailing Address
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Address Line | 1050 HEMLOCK DR
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City | LEWISTON
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State | ID
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Zip | 83501-5434
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Country | US
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Telephone | 208-743-2685
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARCUS CHARLES FOWLER
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Credential |
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Telephone | 208-743-2685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | RC-957
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License Number State | ID
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