=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881734135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TETON VALLEY HOSITAL & SURGICENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 11/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 252 SOUTH MAIN STREET
-----------------------------------------------------
City | VICTOR
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-354-6307
-----------------------------------------------------
Fax | 208-787-7456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 EAST HOWARD AVENUE
-----------------------------------------------------
City | DRIGGS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83422-5112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-354-6307
-----------------------------------------------------
Fax | 208-787-7456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | MRS. LAURA C PIQUET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-354-6302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 31
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------