Provider Demographics
NPI:1710959184
Name:TETON VALLEY HOSPITAL & SURGICENTER
Entity Type:Organization
Organization Name:TETON VALLEY HOSPITAL & SURGICENTER
Other - Org Name:TETON VALLEY HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:QUALITY SERVICES MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PIQUET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-354-6302
Mailing Address - Street 1:120 EAST HOWARD AVENUE
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:208-354-2383
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:120 EAST HOWARD AVENUE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-2383
Practice Address - Fax:208-354-3158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID31282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109085200Medicaid
MT4105075Medicaid
ID002279600Medicaid
ID00273OtherBLUE CROSS
ID000010006342OtherREGENCE BLUE SHIELD
137057Medicare ID - Type Unspecified
131525Medicare ID - Type Unspecified
ID002279600Medicaid
MT4105075Medicaid
ID131313Medicare Oscar/Certification