Provider Demographics
NPI:1770044703
Name:TWO RIVERS MEDICAL GROUP
Entity Type:Organization
Organization Name:TWO RIVERS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRETTYWEASEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-283-7691
Mailing Address - Street 1:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-1311
Mailing Address - Country:US
Mailing Address - Phone:088-283-7691
Mailing Address - Fax:
Practice Address - Street 1:7568 FERRIS AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-5508
Practice Address - Country:US
Practice Address - Phone:208-283-7691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-31
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes251B00000XAgenciesCase Management