Provider Demographics
NPI:1497107171
Name:HIBBERT, MONTE CACHE
Entity Type:Individual
Prefix:
First Name:MONTE
Middle Name:CACHE
Last Name:HIBBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3345
Mailing Address - Country:US
Mailing Address - Phone:208-234-7383
Mailing Address - Fax:
Practice Address - Street 1:121 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3345
Practice Address - Country:US
Practice Address - Phone:208-234-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCFH-4005-SD311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home