Provider Demographics
NPI:1790244424
Name:DESTIN THAYNE BEP INC
Entity Type:Organization
Organization Name:DESTIN THAYNE BEP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:THAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-359-2101
Mailing Address - Street 1:859 S YELLOWSTONE HWY STE 3201
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-6200
Mailing Address - Country:US
Mailing Address - Phone:208-359-2101
Mailing Address - Fax:208-356-8860
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 3201
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6200
Practice Address - Country:US
Practice Address - Phone:208-359-2101
Practice Address - Fax:208-356-8860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty