Provider Demographics
NPI:1700245594
Name:SHAW MOUNTAIN OF CASCADIA, LLC
Entity Type:Organization
Organization Name:SHAW MOUNTAIN OF CASCADIA, LLC
Other - Org Name:SHAW MOUNTAIN OF CASCADIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-9600
Mailing Address - Street 1:909 E RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6508
Mailing Address - Country:US
Mailing Address - Phone:208-343-7717
Mailing Address - Fax:208-692-9909
Practice Address - Street 1:909 E RESERVE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6508
Practice Address - Country:US
Practice Address - Phone:208-343-7717
Practice Address - Fax:208-692-9909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135090Medicare Oscar/Certification