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General NPI Number Information
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NPI Number | 1710857719
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Entity Type | Organization
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Legal Business Name | BRIGHTHAVEN SUPPORTED LIVING LLC
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Dates
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Enumeration Date | 11/06/2025
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 1351 E MONA LISA DR
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City | MERIDIAN
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State | ID
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Zip | 83642-7885
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Country | US
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Telephone | 208-570-9092
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Fax |
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Provider Business Mailing Address
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Address Line | 252 E FRONT ST
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City | BOISE
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State | ID
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Zip | 83702-7348
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Country | US
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Telephone | 208-570-9092
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRUCE ISHIMWE
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Credential |
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Telephone | 208-570-9092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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