Provider Demographics
NPI:1659325132
Name:PEAK MEDICAL IDAHO OPERATIONS LLC
Entity Type:Organization
Organization Name:PEAK MEDICAL IDAHO OPERATIONS LLC
Other - Org Name:REXBURG CARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:660 S 2ND W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2300
Mailing Address - Country:US
Mailing Address - Phone:208-356-0220
Mailing Address - Fax:
Practice Address - Street 1:660 S 2ND W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2300
Practice Address - Country:US
Practice Address - Phone:208-356-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK MEDICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID52314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805165000Medicaid
ID000010013225OtherBLUE SHIELD OF IDAHO
ID01297OtherBLUE CROSS
ID135105Medicare Oscar/Certification