Provider Demographics
NPI:1770504391
Name:TETON VALLEY HOSPITAL & SURGICENTER
Entity Type:Organization
Organization Name:TETON VALLEY HOSPITAL & SURGICENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-354-6317
Mailing Address - Street 1:120 E HOWARD ST
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:208-354-6317
Mailing Address - Fax:
Practice Address - Street 1:120 E HOWARD ST
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:208-354-6317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH-184251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0022800Medicaid
ID000010033856OtherREGENCE BLUE SHIELD OF ID
ID02592OtherBLUE CROSS OF IDAHO
ID0022800Medicaid