Provider Demographics
NPI:1063568178
Name:ASPEN HOME HEALTH PRIVATE DUTY LLC
Entity type:Organization
Organization Name:ASPEN HOME HEALTH PRIVATE DUTY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-9887
Mailing Address - Street 1:PO BOX 3881
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3470 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7579
Practice Address - Country:US
Practice Address - Phone:208-523-9887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH-117251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13-7048Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.