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General NPI Number Information
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NPI Number | 1790244424
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Entity Type | Organization
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Legal Business Name | DESTIN THAYNE BEP INC
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Dates
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Enumeration Date | 03/12/2019
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Last Update Date | 08/12/2021
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Provider Practice Location Address
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Address Line | 859 S YELLOWSTONE HWY STE 3201
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City | REXBURG
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State | ID
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Zip | 83440-6200
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Country | US
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Telephone | 208-359-2101
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Fax | 208-356-8860
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Provider Business Mailing Address
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Address Line | 859 S YELLOWSTONE HWY STE 3201
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City | REXBURG
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State | ID
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Zip | 83440-6200
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Country | US
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Telephone | 208-359-2101
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Fax | 208-356-8860
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Authorized Official
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Title or Position | OWNER
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Name | DESTIN L THAYNE
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Credential |
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Telephone | 208-359-2101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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