Provider Demographics
NPI:1225390131
Name:HOMEDALE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:HOMEDALE HEALTHCARE, INC.
Other - Org Name:OWYHEE HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:108 W OWYHEE AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEDALE
Mailing Address - State:ID
Mailing Address - Zip Code:83628-3206
Mailing Address - Country:US
Mailing Address - Phone:208-337-3168
Mailing Address - Fax:
Practice Address - Street 1:108 W OWYHEE AVE
Practice Address - Street 2:
Practice Address - City:HOMEDALE
Practice Address - State:ID
Practice Address - Zip Code:83628-3206
Practice Address - Country:US
Practice Address - Phone:208-337-3168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135087Medicare Oscar/Certification