Provider Demographics
NPI:1689391161
Name:MOSCOW OF OLYMPUS LLC
Entity Type:Organization
Organization Name:MOSCOW OF OLYMPUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-9600
Mailing Address - Street 1:2205 E RIVERSIDE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7621
Mailing Address - Country:US
Mailing Address - Phone:208-401-9600
Mailing Address - Fax:208-314-0639
Practice Address - Street 1:640 N EISENHOWER ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-9588
Practice Address - Country:US
Practice Address - Phone:208-401-9600
Practice Address - Fax:208-314-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility