=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942178405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYONS SENIOR LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2025
-----------------------------------------------------
Last Update Date | 10/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4334 N BRIGHT ANGEL AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-376-7298
-----------------------------------------------------
Fax | 208-377-8310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4334 N BRIGHT ANGEL AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-376-7298
-----------------------------------------------------
Fax | 208-377-8310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | KAMERON LEMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-376-7298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------