Provider Demographics
NPI:1003803024
Name:NORTHWEST BEC CORP DBA BURLEY CARE CENTER
Entity Type:Organization
Organization Name:NORTHWEST BEC CORP DBA BURLEY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KEDDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:208-678-9474
Mailing Address - Street 1:PO BOX 1224
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-0830
Mailing Address - Country:US
Mailing Address - Phone:208-678-9474
Mailing Address - Fax:208-678-3727
Practice Address - Street 1:1729 MILLER AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2338
Practice Address - Country:US
Practice Address - Phone:208-678-9474
Practice Address - Fax:208-678-3727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID42314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1513121Medicaid
ID804277200Medicaid
ID01289Other314000000X
NV001989033Medicaid
LA1513121Medicaid