Provider Demographics
NPI:1366256943
Name:BONNEVILLE SURGERY CENTER LLC
Entity type:Organization
Organization Name:BONNEVILLE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ORDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-715-8220
Mailing Address - Street 1:2001 S WOODRUFF AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-715-8220
Mailing Address - Fax:208-715-8221
Practice Address - Street 1:2001 S WOODRUFF AVE STE 6
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-715-8220
Practice Address - Fax:208-715-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical