Provider Demographics
NPI:1396859567
Name:TETON MICROBIOLOGY LABORATORY
Entity type:Organization
Organization Name:TETON MICROBIOLOGY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RHYANNA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-0077
Mailing Address - Street 1:258 N WATER AVE
Mailing Address - Street 2:STE. 2
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4057
Mailing Address - Country:US
Mailing Address - Phone:208-529-0077
Mailing Address - Fax:208-522-3797
Practice Address - Street 1:258 N WATER AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4057
Practice Address - Country:US
Practice Address - Phone:208-529-0077
Practice Address - Fax:208-522-3797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8B164OtherBLUE CROSS
ID22387OtherBLUE SHIELD
ID807270200Medicaid
ID8B164OtherBLUE CROSS
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