Provider Demographics
NPI:1083884597
Name:IDAHO CONSUMER DIRECT PERSONAL CARE, LLC
Entity Type:Organization
Organization Name:IDAHO CONSUMER DIRECT PERSONAL CARE, LLC
Other - Org Name:CONSUMER DIRECT PERSONAL CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-532-2001
Mailing Address - Street 1:100 CONSUMER DIRECT WAY
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5037
Mailing Address - Country:US
Mailing Address - Phone:406-532-1900
Mailing Address - Fax:
Practice Address - Street 1:280 E CORPORATE DR STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2952
Practice Address - Country:US
Practice Address - Phone:208-898-0470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8079334-00Medicaid
ID8079334-01Medicaid