Provider Demographics
NPI:1750711362
Name:ST. FILLAN'S, LLC
Entity type:Organization
Organization Name:ST. FILLAN'S, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERBEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-871-4552
Mailing Address - Street 1:226 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2774
Mailing Address - Country:US
Mailing Address - Phone:208-871-4552
Mailing Address - Fax:208-855-0866
Practice Address - Street 1:226 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2774
Practice Address - Country:US
Practice Address - Phone:208-871-4552
Practice Address - Fax:208-855-0866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRHA-4979253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDRHA-4979Medicaid