=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922030352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTHSIDE HOME HEALTH AGENCY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 07/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1403 LEADORE AVE
-----------------------------------------------------
City | SALMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83467-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-756-6383
-----------------------------------------------------
Fax | 208-756-1312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1403 LEADORE AVE
-----------------------------------------------------
City | SALMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83467-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-756-6383
-----------------------------------------------------
Fax | 208-756-1312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTATOR OWNER
-----------------------------------------------------
Name | MRS. HANNA VERMAAS
-----------------------------------------------------
Credential | RN/BSN
-----------------------------------------------------
Telephone | 209-756-6383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HH-135
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------