Provider Demographics
NPI:1083026579
Name:ICARE SUPPORTED LIVING, INC.
Entity Type:Organization
Organization Name:ICARE SUPPORTED LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR/ QIDP
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARI
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:208-695-3505
Mailing Address - Street 1:1903 N WINDSOR PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5584
Mailing Address - Country:US
Mailing Address - Phone:208-695-3505
Mailing Address - Fax:208-955-4130
Practice Address - Street 1:1903 N WINDSOR PARK AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5584
Practice Address - Country:US
Practice Address - Phone:208-695-3505
Practice Address - Fax:208-955-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRHA-5220253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care