Provider Demographics
NPI:1841798857
Name:HAVENWOOD CAREGIVER SERVICES OF IDAHO, LLC
Entity Type:Organization
Organization Name:HAVENWOOD CAREGIVER SERVICES OF IDAHO, LLC
Other - Org Name:ABUNDANT CARE BY HAVENWOOD
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEEFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-327-1011
Mailing Address - Street 1:2417 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5907
Mailing Address - Country:US
Mailing Address - Phone:208-327-1011
Mailing Address - Fax:208-327-1411
Practice Address - Street 1:2417 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5907
Practice Address - Country:US
Practice Address - Phone:208-327-1011
Practice Address - Fax:208-327-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8072875Medicaid