Provider Demographics
NPI:1487823886
Name:BONAVENTURE PLACE RETIREMENT & ASSISTED LIVING COMMUNITY
Entity Type:Organization
Organization Name:BONAVENTURE PLACE RETIREMENT & ASSISTED LIVING COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-566-5715
Mailing Address - Street 1:5850 N FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5466
Mailing Address - Country:US
Mailing Address - Phone:208-429-6544
Mailing Address - Fax:208-429-6739
Practice Address - Street 1:5850 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5466
Practice Address - Country:US
Practice Address - Phone:208-429-6544
Practice Address - Fax:208-429-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service