Basic Information
| Provider Information | |||||||||
| NPI: | 1659426617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TETON CANCER INSTITUTE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TETON CANCER INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2325 CORONADO STREET | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085572700 | ||||||||
| FaxNumber: | 2085572701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1957 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085231100 | ||||||||
| FaxNumber: | 2085572701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | HILLYARD | ||||||||
| AuthorizedOfficialFirstName: | NED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CCO | ||||||||
| AuthorizedOfficialTelephone: | 2085772711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN VIEW HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.