Provider Demographics
NPI:1992734859
Name:ADVANCED HOME MED, LLC
Entity type:Organization
Organization Name:ADVANCED HOME MED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-772-9111
Mailing Address - Street 1:5624 N GOVERNMENT WAY
Mailing Address - Street 2:STE 6
Mailing Address - City:DALTON GDNS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7350
Mailing Address - Country:US
Mailing Address - Phone:208-772-9111
Mailing Address - Fax:208-772-9114
Practice Address - Street 1:5624 N GOVERNMENT WAY
Practice Address - Street 2:STE 6
Practice Address - City:DALTON GDNS
Practice Address - State:ID
Practice Address - Zip Code:83815-7350
Practice Address - Country:US
Practice Address - Phone:208-772-9111
Practice Address - Fax:208-772-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME166332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010137820OtherREGENCE BS OF ID
NV100502494Medicaid
ID806024600Medicaid
IDCC8203OtherBCBS OF ID
ID8I227OtherBLUE CROSS OF ID
WA9054859Medicaid
ID4083160001Medicare NSC