Provider Demographics
NPI:1376211268
Name:KEYSTONE CENTER FOR GERIATRICS LLC
Entity Type:Organization
Organization Name:KEYSTONE CENTER FOR GERIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:208-514-0670
Mailing Address - Street 1:305 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6033
Mailing Address - Country:US
Mailing Address - Phone:208-514-0670
Mailing Address - Fax:
Practice Address - Street 1:305 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6033
Practice Address - Country:US
Practice Address - Phone:208-514-0670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty