MEDICARE: STONEBRIDGE ASSISTED LIVING 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1326702549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONEBRIDGE ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	1670 E 4500 N
Second Line	:
City	:	BUHL
State	:	ID
Zip	:	83316-5303
Country	:	US
Telephone Number	:	801-518-5230
Fax Number	:

Provider Business Practice Location Address
First Line	:	356 E CLEVELAND AVE
Second Line	:
City	:	GLENNS FERRY
State	:	ID
Zip	:	83623-2404
Country	:	US
Telephone Number	:	801-518-5230
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW GAVER
Credential	:
Telephone Number	:	801-518-5230

Provider Enumeration Date	:	10/25/2021
Last Update Date	:	10/25/2021

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