Provider Demographics
NPI:1134130107
Name:LOST RIVERS MEDICAL CENTER
Entity Type:Organization
Organization Name:LOST RIVERS MEDICAL CENTER
Other - Org Name:LOST RIVERS SWINGBED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-527-8206
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213-0145
Mailing Address - Country:US
Mailing Address - Phone:208-527-8206
Mailing Address - Fax:208-527-3105
Practice Address - Street 1:551 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:ARCO
Practice Address - State:ID
Practice Address - Zip Code:83213
Practice Address - Country:US
Practice Address - Phone:208-527-8206
Practice Address - Fax:208-527-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13Z324Medicare Oscar/Certification