Provider Demographics
NPI:1871946483
Name:DOCTOR'S HOSPICE OF IDAHO LLC
Entity type:Organization
Organization Name:DOCTOR'S HOSPICE OF IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:FRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:208-985-2260
Mailing Address - Street 1:1552 N CRESTMONT DR STE B
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2191
Mailing Address - Country:US
Mailing Address - Phone:208-985-2260
Mailing Address - Fax:208-985-2261
Practice Address - Street 1:1552 N CRESTMONT DR STE B
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2191
Practice Address - Country:US
Practice Address - Phone:208-985-2260
Practice Address - Fax:208-985-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1871946483Medicaid