Provider Demographics
NPI:1952441024
Name:VALLEY FACIAL PLASTICS & ENT, PA
Entity Type:Organization
Organization Name:VALLEY FACIAL PLASTICS & ENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-746-0193
Mailing Address - Street 1:330 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-746-0193
Mailing Address - Fax:208-746-7074
Practice Address - Street 1:330 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-746-0193
Practice Address - Fax:208-746-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002456000Medicaid
WA7092091Medicaid
WAGAB11746Medicare PIN
WA7092091Medicaid
ID0417120001Medicare NSC