Provider Demographics
NPI:1194031286
Name:OAK CREEK REHABILITATION CENTER OF KIMBERLY LLC
Entity Type:Organization
Organization Name:OAK CREEK REHABILITATION CENTER OF KIMBERLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-4673
Mailing Address - Street 1:275 S 5TH AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6400
Mailing Address - Country:US
Mailing Address - Phone:208-233-4673
Mailing Address - Fax:208-233-4750
Practice Address - Street 1:500 POLK ST E
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341-1618
Practice Address - Country:US
Practice Address - Phone:208-423-5591
Practice Address - Fax:208-423-5651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID17314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135084Medicare Oscar/Certification