Edgewood Spring Creek Eagle Island LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

RC1104 Issued in ID

Legal business name

EDGEWOOD SPRING CREEK EAGLE ISLAND LLC

Practice address

12426 W Explorer Dr Ste 220
Boise, ID 83713-1560

Phone

(208) 947-4012

NPI assigned

Jan 14, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John Dybwad

Title

VP of Finance

Phone

(701) 757-5422

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1452729600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660867200000",
    "number": "1114383577",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 13238",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "58208",
            "telephone_number": "701-738-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12426 W EXPLORER DR STE 220",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837131560",
            "telephone_number": "208-947-4012"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWOOD SPRING CREEK EAGLE ISLAND LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-14",
        "last_updated": "2022-08-19",
        "certification_date": "2022-08-19",
        "status": "A",
        "authorized_official_last_name": "DYBWAD",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "VP OF FINANCE",
        "authorized_official_telephone_number": "701-757-5422"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "ID",
            "license": "RC1104",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Boise, ID
• Providers in Boise, ID by specialty
• Assisted Living Facility in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.