- Enrollment id
- O20171106001603
- Enrollment state
- ID
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1396261202
- Multiple npi flag
- N
- Ccn
- 135065
- Associate id
- 3274899364
- Organization name
- KELLOG OF CASCADIA LLC
- Doing business as name
- MOUNTAIN VALLEY OF CASCADIA
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- MOUNTAIN VALLEY OF CASCADIA
- Affiliation entity name
- CASCADIA HEALTHCARE
- Affiliation entity id
- 118
- Address line 1
- 601 W CAMERON AVE
- City
- KELLOGG
- State
- ID
- Zip code
- 838372004