Provider Demographics
NPI:1023096757
Name:GOODING REHAB AND LIVING CENTER
Entity type:Organization
Organization Name:GOODING REHAB AND LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SCHOONOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-934-5601
Mailing Address - Street 1:1220 MONTANA ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1856
Mailing Address - Country:US
Mailing Address - Phone:208-934-5601
Mailing Address - Fax:208-934-8154
Practice Address - Street 1:1220 MONTANA ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1856
Practice Address - Country:US
Practice Address - Phone:208-934-5601
Practice Address - Fax:208-934-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID38310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135083Medicare ID - Type Unspecified