Provider Demographics
NPI:1245235878
Name:HOSPICE OF NORTH IDAHO INC
Entity Type:Organization
Organization Name:HOSPICE OF NORTH IDAHO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-772-7994
Mailing Address - Street 1:2290 W PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8424
Mailing Address - Country:US
Mailing Address - Phone:208-772-7994
Mailing Address - Fax:
Practice Address - Street 1:2290 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8424
Practice Address - Country:US
Practice Address - Phone:208-772-7994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002539300Medicaid
ID131504Medicare ID - Type Unspecified