Provider Demographics
NPI:1528184595
Name:KEENE, BRENDA S (CFH)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:S
Last Name:KEENE
Suffix:
Gender:F
Credentials:CFH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 W EMMY CT
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3028
Mailing Address - Country:US
Mailing Address - Phone:208-922-3000
Mailing Address - Fax:208-922-3384
Practice Address - Street 1:1227 W EMMY CT
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-3028
Practice Address - Country:US
Practice Address - Phone:208-922-3000
Practice Address - Fax:208-922-3384
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40434311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0189359Medicaid
ID0189359Medicaid