Provider Demographics
NPI:1427574987
Name:TETON SPORTS & SPINE IMAGING, LLC
Entity Type:Organization
Organization Name:TETON SPORTS & SPINE IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRIKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-201-5380
Mailing Address - Street 1:PO BOX 3083
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3083
Mailing Address - Country:US
Mailing Address - Phone:800-338-5378
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:250 SCOTT LN STE 110
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8060
Practice Address - Country:US
Practice Address - Phone:307-201-5380
Practice Address - Fax:307-201-5202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1427574987Medicaid