=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790309045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE AT FAIRVIEW LAKES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2020
-----------------------------------------------------
Last Update Date | 06/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1960 N LAKES PL
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-5939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-844-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 890 N COLE RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINDA HINES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-867-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------