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General NPI Number Information
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NPI Number | 1639349004
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Entity Type | Organization
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Legal Business Name | VINES OF LIFE
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Dates
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Enumeration Date | 03/03/2008
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Last Update Date | 03/03/2008
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Provider Practice Location Address
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Address Line | 11088 W EDNA ST
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City | BOISE
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State | ID
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Zip | 83713-3829
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Country | US
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Telephone | 208-378-7581
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Fax | 208-322-2977
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Provider Business Mailing Address
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Address Line | 11088 W EDNA ST
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City | BOISE
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State | ID
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Zip | 83713-3829
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Country | US
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Telephone | 208-378-7581
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Fax | 208-322-2977
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. JESSICA R VIALPANDO
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Credential | MS CCC-SLP, RCA
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Telephone | 208-378-7581
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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 | RC899
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License Number State | ID
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