1952729857 NPI number — BRIDGER VALLEY URGENT CARE, LLC

Table of content: (NPI 1952729857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952729857 NPI number — BRIDGER VALLEY URGENT CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGER VALLEY URGENT CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952729857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 S. WOODRUFF AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83401-5543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-542-9111
Provider Business Mailing Address Fax Number:
208-542-9114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3580 STATE HIGHWAY 414
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYMAN
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-9111
Provider Business Practice Location Address Fax Number:
208-542-9114
Provider Enumeration Date:
03/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GOBLE
Authorized Official First Name:
EDWIN
Authorized Official Middle Name:
MARLOWE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-542-9111

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2650A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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