Provider Demographics
NPI:1467113233
Name:IDAHO FALLS OF CASCADIA, LLC
Entity Type:Organization
Organization Name:IDAHO FALLS OF CASCADIA, LLC
Other - Org Name:TETON HEALTHCARE OF CASCADIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-9600
Mailing Address - Street 1:2205 E RIVERSIDE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7621
Mailing Address - Country:US
Mailing Address - Phone:208-401-9600
Mailing Address - Fax:
Practice Address - Street 1:3111 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7534
Practice Address - Country:US
Practice Address - Phone:208-529-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility