Provider Demographics
NPI:1407239973
Name:HUMANGOOD IDAHO
Entity Type:Organization
Organization Name:HUMANGOOD IDAHO
Other - Org Name:THE TERRACES OF BOISE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUD
Authorized Official - Middle Name:S
Authorized Official - Last Name:SEVERNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-336-5550
Mailing Address - Street 1:5301 E WARM SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716
Mailing Address - Country:US
Mailing Address - Phone:208-336-5550
Mailing Address - Fax:
Practice Address - Street 1:5301 E WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716
Practice Address - Country:US
Practice Address - Phone:208-336-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135141Medicare Oscar/Certification