Healthcare Provider Details

I. General information

NPI: 1669533154
Provider Name (Legal Business Name): CARIBOU MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 3RD W
SODA SPRINGS ID
83276-1559
US

IV. Provider business mailing address

300 S 3RD W
SODA SPRINGS ID
83276-1559
US

V. Phone/Fax

Practice location:
  • Phone: 208-547-3341
  • Fax: 208-547-2790
Mailing address:
  • Phone: 208-547-3341
  • Fax: 208-547-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA THOMAS
Title or Position: CEO
Credential:
Phone: 208-547-2765