Basic Information
| Provider Information | |||||||||
| NPI: | 1144470493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNION | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | PAIGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 GARRETT WAY | ||||||||
| Address2: | STE 1 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Practice Location | |||||||||
| Address1: | 4980 W STATE ST STE A | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837033326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086391649 | ||||||||
| FaxNumber: | 2086390813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 372500000X | N | Nursing Service Related Providers | Chore Provider | 372600000X | ID | N | Nursing Service Related Providers | Adult Companion | 3747P1801X | ID | N | Nursing Service Related Providers | Technician | Personal Care Attendant | 376J00000X | ID | Y | Nursing Service Related Providers | Homemaker |
ID Information
| ID | Type | State | Issuer | Description | 1144470493 | 05 | ID | MEDICAID |