Provider Demographics
NPI:1083095046
Name:MAGIC VALLEY SENIOR LIVING, INC.
Entity Type:Organization
Organization Name:MAGIC VALLEY SENIOR LIVING, INC.
Other - Org Name:WOODSTONE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-487-9500
Mailing Address - Street 1:491 CASWELL AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3743
Mailing Address - Country:US
Mailing Address - Phone:208-734-6062
Mailing Address - Fax:
Practice Address - Street 1:491 CASWELL AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3743
Practice Address - Country:US
Practice Address - Phone:208-734-6062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRC1089310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility