Provider Demographics
NPI:1376674622
Name:SPRING CREEK IDAHO, LLC
Entity Type:Organization
Organization Name:SPRING CREEK IDAHO, LLC
Other - Org Name:SPRING CREEK MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-855-5005
Mailing Address - Street 1:253 E CALDERWOOD DR # E
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7500
Mailing Address - Country:US
Mailing Address - Phone:208-855-5005
Mailing Address - Fax:208-855-5034
Practice Address - Street 1:175 E CALDERWOOD DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7482
Practice Address - Country:US
Practice Address - Phone:208-884-6199
Practice Address - Fax:208-639-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8059942000Medicaid