Provider Demographics
NPI:1073697884
Name:UPPER VALLEY FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:UPPER VALLEY FAMILY MEDICINE PLLC
Other - Org Name:UPPER VALLEY FAMILY MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-745-5021
Mailing Address - Street 1:711 RIGBY LAKE DR STE 115
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5230
Mailing Address - Country:US
Mailing Address - Phone:208-745-5021
Mailing Address - Fax:208-745-5026
Practice Address - Street 1:711 RIGBY LAKE DR STE 115
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5230
Practice Address - Country:US
Practice Address - Phone:208-745-5021
Practice Address - Fax:208-745-5026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8067451700Medicaid
ID806913600Medicaid
ID806913600Medicaid