MEDICARE: TETON CANCER INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1659426617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TETON CANCER INSTITUTE

Provider Business Mailing Address
First Line	:	2325 CORONADO STREET
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404
Country	:	US
Telephone Number	:	208-557-2700
Fax Number	:	208-557-2701

Provider Business Practice Location Address
First Line	:	1957 E 17TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6429
Country	:	US
Telephone Number	:	208-523-1100
Fax Number	:	208-557-2701

Authorized Official
Title or Position	:	CCO
Name	:	NED HILLYARD
Credential	:
Telephone Number	:	208-577-2711

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	02/04/2014

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