Provider Demographics
NPI:1831662311
Name:CACHE VALLEY VEIN
Entity Type:Organization
Organization Name:CACHE VALLEY VEIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STROBEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-542-5000
Mailing Address - Street 1:PO BOX 3155
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3155
Mailing Address - Country:US
Mailing Address - Phone:208-552-8579
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:565 W 465 N STE 130
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-4802
Practice Address - Country:US
Practice Address - Phone:435-753-2842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-07
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1831662311Medicaid