Healthcare Provider Details

I. General information

NPI: 1881734135
Provider Name (Legal Business Name): TETON VALLEY HOSITAL & SURGICENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 SOUTH MAIN STREET
VICTOR ID
83455
US

IV. Provider business mailing address

120 EAST HOWARD AVENUE
DRIGGS ID
83422-5112
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-6307
  • Fax: 208-787-7456
Mailing address:
  • Phone: 208-354-6307
  • Fax: 208-787-7456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number31
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number31
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number31
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31
License Number StateID
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31
License Number StateID

VIII. Authorized Official

Name: MRS. LAURA C PIQUET
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 208-354-6302