Healthcare Provider Details

I. General information

NPI: 1689651481
Provider Name (Legal Business Name): TETON OUTPATIENT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BUFFALO WAY
JACKSON WY
83001-2530
US

IV. Provider business mailing address

14201 DALLAS PKWY
DALLAS TX
75254-2916
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-8677
  • Fax: 307-734-7365
Mailing address:
  • Phone: 307-733-8677
  • Fax: 307-734-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0713016
License Number StateWY

VIII. Authorized Official

Name: ERIC BOON
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 480-567-0269