Provider Demographics
NPI:1750309795
Name:SHOSHONE REHAB AND LIVING CENTER
Entity Type:Organization
Organization Name:SHOSHONE REHAB AND LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-886-2228
Mailing Address - Street 1:511 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-5380
Mailing Address - Country:US
Mailing Address - Phone:208-886-2228
Mailing Address - Fax:208-886-2549
Practice Address - Street 1:511 EAST 4TH STREET
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352
Practice Address - Country:US
Practice Address - Phone:208-886-2228
Practice Address - Fax:208-886-2549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID20314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135056Medicare ID - Type UnspecifiedMEDICARE