Provider Demographics
NPI:1053305144
Name:TETON MRI OF IDAHO FALLS
Entity Type:Organization
Organization Name:TETON MRI OF IDAHO FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-552-0828
Mailing Address - Street 1:2060 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6396
Mailing Address - Country:US
Mailing Address - Phone:208-552-0828
Mailing Address - Fax:208-552-0829
Practice Address - Street 1:2060 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6396
Practice Address - Country:US
Practice Address - Phone:208-552-0828
Practice Address - Fax:208-552-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology