Provider Demographics
NPI:1952729857
Name:BRIDGER VALLEY URGENT CARE, LLC
Entity Type:Organization
Organization Name:BRIDGER VALLEY URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:MARLOWE
Authorized Official - Last Name:GOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-542-9111
Mailing Address - Street 1:740 S. WOODRUFF AVE.
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5543
Mailing Address - Country:US
Mailing Address - Phone:208-542-9111
Mailing Address - Fax:208-542-9114
Practice Address - Street 1:3580 STATE HIGHWAY 414
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:WY
Practice Address - Zip Code:82937
Practice Address - Country:US
Practice Address - Phone:208-542-9111
Practice Address - Fax:208-542-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-29
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2650A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty