Provider Demographics
NPI:1790340834
Name:IDAHO SURGICAL, LLC
Entity Type:Organization
Organization Name:IDAHO SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-854-9828
Mailing Address - Street 1:1662 S LAKE CREST WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6195 E HUNT AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8317
Practice Address - Country:US
Practice Address - Phone:208-639-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1629244355Medicaid