Provider Demographics
NPI:1477260636
Name:BENEVOLENT ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:BENEVOLENT ASSISTED LIVING LLC
Other - Org Name:HEIRLOOM HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:RUFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-813-6449
Mailing Address - Street 1:1532 W POWDER CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4876
Mailing Address - Country:US
Mailing Address - Phone:986-888-7684
Mailing Address - Fax:
Practice Address - Street 1:9976 W PATTIE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-2900
Practice Address - Country:US
Practice Address - Phone:208-813-6449
Practice Address - Fax:208-813-6462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDITPID018229Medicaid