MEDICARE: IDAHO FALLS NORTH OF CASCADIA, 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1972220473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO FALLS NORTH OF CASCADIA, LLC

Provider Business Mailing Address
First Line	:	2205 E RIVERSIDE DR STE 100
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-7621
Country	:	US
Telephone Number	:	208-401-9600
Fax Number	:	208-314-0639

Provider Business Practice Location Address
First Line	:	840 E ELVA ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2801
Country	:	US
Telephone Number	:	208-401-9600
Fax Number	:	208-314-0639

Authorized Official
Title or Position	:	PRESIDENT
Name	:	OWEN HAMMOND
Credential	:
Telephone Number	:	208-401-9600

Provider Enumeration Date	:	10/25/2022
Last Update Date	:	05/24/2024

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