Healthcare Provider Details

I. General information

NPI: 1538347034
Provider Name (Legal Business Name): BYU IDAHO STUDENT HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SHC
REXBURG ID
83460-2010
US

IV. Provider business mailing address

100 SHC
REXBURG ID
83460-2010
US

V. Phone/Fax

Practice location:
  • Phone: 208-496-1300
  • Fax: 208-496-1306
Mailing address:
  • Phone: 208-496-1300
  • Fax: 208-496-1306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAWN B ORR
Title or Position: DIRECTOR OF HEALTHCARE CENTER
Credential: MBA
Phone: 208-496-3434