Organization
HENRYS FORK SURGERY CENTER PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEREMY JOHNSON (MANAGER)
(208) 359-1888
Entity
Organization
Contact information
Practice address
23 SAWTELLE AVE, REXBURG, ID 83440
(208) 359-1888
(208) 359-1889
Mailing address
PO BOX 6, REXBURG, ID 83440-0006
(208) 359-1888
(208) 359-1888
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1447301395
—
ID
Enumeration date
04/08/2020
Last updated
06/19/2025
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