Healthcare Provider Details

I. General information

NPI: 1952729857
Provider Name (Legal Business Name): BRIDGER VALLEY URGENT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 03/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 STATE HIGHWAY 414
LYMAN WY
82937
US

IV. Provider business mailing address

740 S. WOODRUFF AVE.
IDAHO FALLS ID
83401-5543
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-9111
  • Fax: 208-542-9114
Mailing address:
  • Phone: 208-542-9111
  • Fax: 208-542-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2650A
License Number StateWY

VIII. Authorized Official

Name: DR. EDWIN MARLOWE GOBLE
Title or Position: OWNER
Credential: M.D.
Phone: 208-542-9111