Provider Demographics
NPI:1306608104
Name:IDAHO LUNG AND HEART
Entity type:Organization
Organization Name:IDAHO LUNG AND HEART
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-359-9570
Mailing Address - Street 1:38 S 2ND E STE 2
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2675
Mailing Address - Country:US
Mailing Address - Phone:801-616-7253
Mailing Address - Fax:
Practice Address - Street 1:38 S 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2671
Practice Address - Country:US
Practice Address - Phone:801-616-7253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty