Healthcare Provider Details

I. General information

NPI: 1699784413
Provider Name (Legal Business Name): TETON CARDIOVASCULAR AND PULMONARY LAB,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S WOODRUFF AVE SUITE 12 B
IDAHO FALLS ID
83404-6374
US

IV. Provider business mailing address

PO BOX 2559
BURLESON TX
76097-2559
US

V. Phone/Fax

Practice location:
  • Phone: 800-341-1043
  • Fax: 208-528-7971
Mailing address:
  • Phone: 800-341-1043
  • Fax: 208-528-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRADEN L CAZARES
Title or Position: CEO
Credential:
Phone: 972-677-3896