Organization
GRAND TETON SURGICAL CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERESA WELLARD R.N. (DIRECTOR OF NURSING)
(208) 524-3800
Entity
Organization
Contact information
Practice address
2290 CORONADO ST, IDAHO FALLS, ID 83404-7552
(208) 524-3800
(208) 524-3805
Mailing address
2290 CORONADO ST, IDAHO FALLS, ID 83404-7552
(208) 524-3800
(208) 524-3805
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010005323
REGENCE BLUE SHIELD
ID
01
—
03772
BLUE CROSS
ID
05
—
805482600
—
ID
Enumeration date
06/14/2005
Last updated
03/02/2010
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