Basic Information
| Provider Information | |||||||||
| NPI: | 1487240925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY VISTA CARE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 ELM DR | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838612119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 ELM DR | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838612119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | BORGMAN | ||||||||
| AuthorizedOfficialFirstName: | KASEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 2082454576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY VISTA COTTAGE CARE | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | RC1236 | 01 | ID | STATE OF IDAHO DEPT OF HEALTH AND WELFARE | OTHER |