Healthcare Provider Details

I. General information

NPI: 1417405606
Provider Name (Legal Business Name): TETON VALLEY HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E LITTLE AVE
DRIGGS ID
83422-5138
US

IV. Provider business mailing address

120 E HOWARD ST
DRIGGS ID
83422-5112
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-6302
  • Fax: 208-354-3158
Mailing address:
  • Phone: 208-354-6302
  • Fax: 208-354-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number31
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31
License Number StateID

VIII. Authorized Official

Name: LAURA C PIQUET
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 208-354-6302