MEDICARE: ASC IDAHO LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1275389918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASC IDAHO LLC.

Provider Business Mailing Address
First Line	:	1120 S RACKHAM WAY STE 300
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-1092
Country	:	US
Telephone Number	:	208-593-2093
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 S RACKHAM WAY STE 300
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-1092
Country	:	US
Telephone Number	:	208-593-2093
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	ERIC BRIAN LISKER
Credential	:
Telephone Number	:	949-403-8451

Provider Enumeration Date	:	04/24/2024
Last Update Date	:	01/15/2025

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Directions to “ASC IDAHO LLC. ” Practice Location

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