Provider Demographics
NPI:1215756952
Name:AEGIS IDAHO LLC
Entity type:Organization
Organization Name:AEGIS IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:435-723-9000
Mailing Address - Street 1:30 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1237
Mailing Address - Country:US
Mailing Address - Phone:435-723-9000
Mailing Address - Fax:435-734-9819
Practice Address - Street 1:30 N STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1237
Practice Address - Country:US
Practice Address - Phone:435-723-9000
Practice Address - Fax:435-734-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based