Provider Demographics
NPI:1396133732
Name:LONGSHOT ENTERPRISES, INC.
Entity type:Organization
Organization Name:LONGSHOT ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-2380
Mailing Address - Street 1:353 E LANDER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6314
Mailing Address - Country:US
Mailing Address - Phone:208-234-2380
Mailing Address - Fax:208-234-8040
Practice Address - Street 1:353 E LANDER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6314
Practice Address - Country:US
Practice Address - Phone:208-234-2380
Practice Address - Fax:208-234-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health