National Provider Identifier Database

HENRYS FORK SURGERY CENTER PLLC
Ambulatory Surgical


Contact Information

HENRYS FORK SURGERY CENTER PLLC
23 SAWTELLE AVE
REXBURG, ID83440
Phone: 208-359-1888
Fax: 208-359-1889
Website:
Specialty Taxonomy Code
* Ambulatory Surgical 261QA1903X

* Indicates primary specialty

NPI Profile & details for HENRYS FORK SURGERY CENTER PLLC

NPI Number 1235768490
Legal business name
LBN
HENRYS FORK SURGERY CENTER PLLC
Authorized official JEREMY JOHNSON - (MANAGER)
Entity Organization
Organization subpart No
Enumeration date 04/08/2020
Last updated 06/19/2025 - About 12 months ago
Sole proprietor1 Not specified
Identifiers
  • ID Medicaid: 1447301395

1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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