Provider Demographics
NPI:1275283954
Name:WOODLAND ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:WOODLAND ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRABTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-731-0862
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-0547
Mailing Address - Country:US
Mailing Address - Phone:208-731-4222
Mailing Address - Fax:
Practice Address - Street 1:19937C HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316-5511
Practice Address - Country:US
Practice Address - Phone:208-731-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAOOO2434Medicaid