Provider Demographics
NPI:1629252994
Name:QUALICARE INC.
Entity Type:Organization
Organization Name:QUALICARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BART
Authorized Official - Middle Name:O
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:208-542-1388
Mailing Address - Street 1:3539 BRIAR CREEK LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4761
Mailing Address - Country:US
Mailing Address - Phone:208-542-1388
Mailing Address - Fax:208-552-7847
Practice Address - Street 1:3539 BRIAR CREEK LN
Practice Address - Street 2:SUITE A
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4761
Practice Address - Country:US
Practice Address - Phone:208-542-1388
Practice Address - Fax:208-552-7847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC132647251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8055151Medicaid
ID8058569Medicaid
ID8068114Medicaid