Provider Demographics
NPI:1417405606
Name:TETON VALLEY HEALTHCARE, INC
Entity Type:Organization
Organization Name:TETON VALLEY HEALTHCARE, INC
Other - Org Name:CACHE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PIQUET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-354-6302
Mailing Address - Street 1:120 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6302
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:30 E LITTLE AVE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5138
Practice Address - Country:US
Practice Address - Phone:208-354-6302
Practice Address - Fax:208-354-3158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON VALLEY HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID31207Q00000X, 363AM0700X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6OtherRETAIL CLINIC