Provider Demographics
NPI:1558368233
Name:WESTERN VISITING NURSES, INC.
Entity Type:Organization
Organization Name:WESTERN VISITING NURSES, INC.
Other - Org Name:WESTERN CHOICE HOME SERVICES, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEXTRAL
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:208-522-3291
Mailing Address - Street 1:1400 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4253
Mailing Address - Country:US
Mailing Address - Phone:208-522-3291
Mailing Address - Fax:208-529-3914
Practice Address - Street 1:1400 BENTON ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4253
Practice Address - Country:US
Practice Address - Phone:208-522-3291
Practice Address - Fax:208-529-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH-195251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002538000Medicaid
ID002568200Medicaid
ID002568200Medicaid