Healthcare Provider Details

I. General information

NPI: 1831134584
Provider Name (Legal Business Name): REXBURG SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 EAST 4TH NORTH SUITE 200
REXBURG ID
83440
US

IV. Provider business mailing address

381 EAST 4TH NORTH SUITE 200
REXBURG ID
83440
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-2300
  • Fax:
Mailing address:
  • Phone: 208-359-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateID

VIII. Authorized Official

Name: DR. DWAYNE M HANSEN
Title or Position: BOARD CHAIRMAN
Credential: M.D.
Phone: 208-359-2300