Provider Demographics
NPI:1477086114
Name:TETON SUPPORTED LIVING LLC
Entity Type:Organization
Organization Name:TETON SUPPORTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:208-377-0580
Mailing Address - Street 1:4101 N CRESWELL WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2404
Mailing Address - Country:US
Mailing Address - Phone:208-377-0580
Mailing Address - Fax:208-672-1388
Practice Address - Street 1:4101 N CRESWELL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2404
Practice Address - Country:US
Practice Address - Phone:208-377-0580
Practice Address - Fax:208-672-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services