MEDICARE: TREASURE VALLEY ADVANCED CONCEPTS 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	251B00000X	Case Management Agency		ID

General Provider Information

NPI Number	:	1518314145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREASURE VALLEY ADVANCED CONCEPTS LLC

Provider Business Mailing Address
First Line	:	210 HOLLY ST
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-5104
Country	:	US
Telephone Number	:	208-573-1576
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 HOLLY ST
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-5104
Country	:	US
Telephone Number	:	208-573-1576
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TAMMY LOUISE GUSMAN
Credential	:	BA
Telephone Number	:	208-573-1576

Provider Enumeration Date	:	05/24/2016
Last Update Date	:	05/24/2016

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