Provider Demographics
NPI:1609358761
Name:CARDIAC CATH LAB OF IDAHO FALLS
Entity Type:Organization
Organization Name:CARDIAC CATH LAB OF IDAHO FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:FOURNET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-574-1015
Mailing Address - Street 1:2200 POST OAK BLVD STE 1525
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-4711
Mailing Address - Country:US
Mailing Address - Phone:713-574-1015
Mailing Address - Fax:832-271-1037
Practice Address - Street 1:3311 VALENCIA DRIVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:415-218-9820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty