Basic Information
| Provider Information | |||||||||
| NPI: | 1831662311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CACHE VALLEY VEIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3155 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085528579 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 W 465 N STE 130 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843324802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357532842 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2019 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | STROBEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2085425000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1831662311 | 05 | UT | MEDICAID |