Healthcare Provider Details

I. General information

NPI: 1053669598
Provider Name (Legal Business Name): TETON VALLEY HEALTH CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E HOWARD AVENUE
DRIGGS ID
83422-5112
US

IV. Provider business mailing address

120 E HOWARD AVENUE
DRIGGS ID
83422-5112
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-2383
  • Fax: 208-354-3158
Mailing address:
  • Phone: 208-354-2383
  • Fax: 208-354-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number31
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number31
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number31
License Number StateID

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. JILL PAYNE
Title or Position: CHIEF OF COMPLIANCE
Credential:
Phone: 208-354-6302