Provider Demographics
NPI:1356652168
Name:VALLEY VISTA APARTMENTS
Entity Type:Organization
Organization Name:VALLEY VISTA APARTMENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BORGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-245-4576
Mailing Address - Street 1:820 ELM DR
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2119
Mailing Address - Country:US
Mailing Address - Phone:208-245-4576
Mailing Address - Fax:208-245-2138
Practice Address - Street 1:820 ELM DR
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2119
Practice Address - Country:US
Practice Address - Phone:208-245-4576
Practice Address - Fax:208-245-2138
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY VISTA CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM0026110-004Medicaid