Provider Demographics
NPI:1194159764
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:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAWL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-398-8250
Mailing Address - Street 1:815 S BRIDGE WAY PL STE 116
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6021
Mailing Address - Country:US
Mailing Address - Phone:208-938-8250
Mailing Address - Fax:208-938-4068
Practice Address - Street 1:4205 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2036
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:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8080968Medicaid