Provider Demographics
NPI:1801143029
Name:TETON VALLEY HEALTH CARE, INC
Entity type:Organization
Organization Name:TETON VALLEY HEALTH CARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:JILL PAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-354-6352
Mailing Address - Street 1:120 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6302
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:83 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-0368
Practice Address - Country:US
Practice Address - Phone:208-354-6307
Practice Address - Fax:208-787-7456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207LP2900X, 363LP0200X, 207Q00000X, 207X00000X, 207XX0005X, 208000000X, 363AM0700X, 363L00000X
ID31208600000X, 208VP0014X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20001842Medicare Oscar/Certification
ID138510Medicare Oscar/Certification