Provider Demographics
NPI:1831654243
Name:MINI-CASSIA HEARTS 4 SENIORS
Entity Type:Organization
Organization Name:MINI-CASSIA HEARTS 4 SENIORS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-312-5715
Mailing Address - Street 1:2450 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2933
Mailing Address - Country:US
Mailing Address - Phone:208-878-5715
Mailing Address - Fax:208-878-5716
Practice Address - Street 1:135 EAST 23RD DRIVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318
Practice Address - Country:US
Practice Address - Phone:208-312-5715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-11
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0003627Medicaid