Provider Demographics
NPI:1083002240
Name:TRACY IRENE DAVIDSON
Entity Type:Organization
Organization Name:TRACY IRENE DAVIDSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-255-6804
Mailing Address - Street 1:493493 HIGHWAY 95 RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:ID
Mailing Address - Zip Code:83847-4913
Mailing Address - Country:US
Mailing Address - Phone:208-255-6804
Mailing Address - Fax:
Practice Address - Street 1:493493 HIGHWAY 95 RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:ID
Practice Address - Zip Code:83847-4913
Practice Address - Country:US
Practice Address - Phone:208-255-6804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances