Healthcare Provider Details

I. General information

NPI: 1003349465
Provider Name (Legal Business Name): TETON SURGICAL ASSIST SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MELODY CREEK LN
JACKSON WY
83001-8982
US

IV. Provider business mailing address

1200 MELODY CREEK LN
JACKSON WY
83001-8982
US

V. Phone/Fax

Practice location:
  • Phone: 307-413-6424
  • Fax:
Mailing address:
  • Phone: 307-413-6424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number29304
License Number StateWY

VIII. Authorized Official

Name: JILL VATTER
Title or Position: SOLE MEMBER
Credential: RNFA
Phone: 307-413-6424