Provider Demographics
NPI:1821864125
Name:ALLEGIANT IDAHO, LLC
Entity Type:Organization
Organization Name:ALLEGIANT IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-466-0987
Mailing Address - Street 1:119 S VALLEY DR # 114
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2974
Mailing Address - Country:US
Mailing Address - Phone:208-466-0987
Mailing Address - Fax:208-466-0985
Practice Address - Street 1:210 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5013
Practice Address - Country:US
Practice Address - Phone:208-466-0987
Practice Address - Fax:208-466-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID251J00000XMedicaid