Provider Demographics
NPI:1710072954
Name:TETON NUCLEAR MEDICINE SERVICE
Entity Type:Organization
Organization Name:TETON NUCLEAR MEDICINE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:PENA
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:RADIATION SAFETY OFF
Authorized Official - Phone:208-525-3201
Mailing Address - Street 1:2001 S WOODRUFF
Mailing Address - Street 2:SUITE 20
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-525-3201
Mailing Address - Fax:208-525-8896
Practice Address - Street 1:2001 S WOODRUFF
Practice Address - Street 2:SUITE 20
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-525-3201
Practice Address - Fax:208-525-8896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Not Answered207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10606753OtherBLUE SHIELD
89763OtherBLUE CROSS
10606753OtherBLUE SHIELD