Provider Demographics
NPI:1841295227
Name:GRAND TETON SURGICAL CENTER LLC
Entity type:Organization
Organization Name:GRAND TETON SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-524-3800
Mailing Address - Street 1:2290 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7552
Mailing Address - Country:US
Mailing Address - Phone:208-524-3800
Mailing Address - Fax:208-524-3805
Practice Address - Street 1:2290 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7552
Practice Address - Country:US
Practice Address - Phone:208-524-3800
Practice Address - Fax:208-524-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID03772OtherBLUE CROSS
ID000010005323OtherREGENCE BLUE SHIELD
ID805482600Medicaid
ID805482600Medicaid