Provider Demographics
NPI:1699784413
Name:TETON CARDIOVASCULAR AND PULMONARY LAB,LLC
Entity type:Organization
Organization Name:TETON CARDIOVASCULAR AND PULMONARY LAB,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAZARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-677-3896
Mailing Address - Street 1:PO BOX 2559
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76097-2559
Mailing Address - Country:US
Mailing Address - Phone:800-341-1043
Mailing Address - Fax:208-528-7971
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 12 B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:800-341-1043
Practice Address - Fax:208-528-7971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807391800Medicaid
ID000010153937OtherBLUE SHIELD OF IDAHO
ID8M795OtherBLUE CROSS OF IDAHO