Provider Demographics
NPI:1518115773
Name:CHAROLAIS CARE IV, INC
Entity Type:Organization
Organization Name:CHAROLAIS CARE IV, INC
Other - Org Name:LINCOLN COUNTY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-4673
Mailing Address - Street 1:511 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-5380
Mailing Address - Country:US
Mailing Address - Phone:208-886-2226
Mailing Address - Fax:208-886-2549
Practice Address - Street 1:511 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352-5380
Practice Address - Country:US
Practice Address - Phone:208-886-2228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135056Medicare Oscar/Certification