Provider Demographics
NPI:1023273430
Name:TDANDC LLC
Entity type:Organization
Organization Name:TDANDC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAWL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-342-3013
Mailing Address - Street 1:1111 S ORCHARD ST STE 208
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1922
Mailing Address - Country:US
Mailing Address - Phone:208-342-3013
Mailing Address - Fax:208-344-3502
Practice Address - Street 1:1111 S ORCHARD ST
Practice Address - Street 2:208
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1966
Practice Address - Country:US
Practice Address - Phone:208-342-3013
Practice Address - Fax:208-344-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8080963-01Medicaid
ID8080968-00Medicaid
ID8080963-00Medicaid
ID8080968-01Medicaid