Provider Demographics
NPI:1760438964
Name:BLAINE MANOR
Entity Type:Organization
Organization Name:BLAINE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOGLIA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-578-3502
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-0927
Mailing Address - Country:US
Mailing Address - Phone:208-578-3504
Mailing Address - Fax:208-788-7210
Practice Address - Street 1:706 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333
Practice Address - Country:US
Practice Address - Phone:208-578-3504
Practice Address - Fax:208-788-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDH6314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135069Medicare Oscar/Certification
ID5469580001Medicare NSC