Provider Demographics
NPI:1992494389
Name:MAGIC VALLEY SLEEP INSTITUTE LLC
Entity type:Organization
Organization Name:MAGIC VALLEY SLEEP INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTUIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-308-2596
Mailing Address - Street 1:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1657
Mailing Address - Country:US
Mailing Address - Phone:208-734-3356
Mailing Address - Fax:855-898-0004
Practice Address - Street 1:340 N HAVEN DR
Practice Address - Street 2:101
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3392
Practice Address - Country:US
Practice Address - Phone:208-734-3356
Practice Address - Fax:855-898-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-02
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty