Provider Demographics
NPI:1003982927
Name:LACROSSE HEALTH- COEUR D'ALENE, LLC
Entity Type:Organization
Organization Name:LACROSSE HEALTH- COEUR D'ALENE, LLC
Other - Org Name:LACROSSE HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOV
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-678-4426
Mailing Address - Street 1:210 WEST LACROSSE AVENUE
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2403
Mailing Address - Country:US
Mailing Address - Phone:208-664-2185
Mailing Address - Fax:208-664-1604
Practice Address - Street 1:210 W LACROSSE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2403
Practice Address - Country:US
Practice Address - Phone:208-664-2185
Practice Address - Fax:208-664-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000283700Medicaid
ID135042Medicare Oscar/Certification