Provider Demographics
NPI:1356008825
Name:SAGE CREST RETIREMENT VILLAGE LTD
Entity Type:Organization
Organization Name:SAGE CREST RETIREMENT VILLAGE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-536-3602
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-0387
Mailing Address - Country:US
Mailing Address - Phone:208-536-3602
Mailing Address - Fax:
Practice Address - Street 1:500 CREST LINE DR
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316
Practice Address - Country:US
Practice Address - Phone:208-536-3602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility