Provider Demographics
NPI:1679562011
Name:DIVISION OF VETERANS SERVICES
Entity Type:Organization
Organization Name:DIVISION OF VETERANS SERVICES
Other - Org Name:IDAHO STATE VETERANS HOME - LEWISTON
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASUELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-334-3513
Mailing Address - Street 1:821 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6389
Mailing Address - Country:US
Mailing Address - Phone:208-799-3422
Mailing Address - Fax:208-799-3414
Practice Address - Street 1:821 21ST AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6389
Practice Address - Country:US
Practice Address - Phone:208-799-3422
Practice Address - Fax:208-799-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID91314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1042HPOtherPHARMACY LICENSE
ID805788200Medicaid
ID805741800Medicaid
ID1307102OtherNABP PHARMACY
ID91OtherNURSING FACILITY LICENSE
ID91OtherNURSING FACILITY LICENSE
ID1042HPOtherPHARMACY LICENSE