NPIMap

Organization Active NPI

Henrys Fork Surgery Center PLLC

  • Ambulatory Surgical Clinic/Center
  • Rexburg, ID
National Provider Identifier
1235768490
Registry record updated Jun 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
HENRYS FORK SURGERY CENTER PLLC
Practice address
23 Sawtelle Ave
Rexburg, ID 83440
Phone
(208) 359-1888
Fax
(208) 359-1889
NPI assigned
Apr 8, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeremy Johnson
Title
Manager
Phone
(208) 359-1888

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X Primary

Addresses

Primary practice location

23 Sawtelle Ave
Rexburg, ID 83440

Mailing address

PO Box 6
Rexburg, ID 83440-0006
Phone (208) 359-1888

Other identifiers 1

IdentifierTypeStateIssuer
1447301395MedicaidID

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address manager@rexburgeyes.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20201216001788 ID Part B Supplier - Ambulatory Surgical Center 3375955388 Receives reassigned benefits from 2 practitioners
Practice locations: Rexburg, ID
O20250612003137 ID Part B Supplier - Ambulatory Surgical Center 3375955388 Receives reassigned benefits from 1 practitioner
Practice locations: Idaho Falls, ID
O20250619001417 ID Part B Supplier - Ambulatory Surgical Center 3375955388 Receives reassigned benefits from 3 practitioners
Practice locations: Chubbuck, ID

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
Henrys Fork Surgery Center PLLCCCN 13C0001087
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1586304000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750291200000",
    "number": "1235768490",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 6",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834400006",
            "telephone_number": "208-359-1888",
            "fax_number": "208-359-1888"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "23 SAWTELLE AVE",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "83440",
            "telephone_number": "208-359-1888",
            "fax_number": "208-359-1889"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HENRYS FORK SURGERY CENTER PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-04-08",
        "last_updated": "2025-06-19",
        "certification_date": "2025-05-20",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "JEREMY",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "208-359-1888"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1447301395",
            "state": "ID"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "manager@rexburgeyes.com",
            "affiliation": "N",
            "endpointDescription": "Manager Email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Email",
            "address_1": "23 Sawtelle Ave",
            "city": "Rexburg",
            "state": "ID",
            "country_code": "US",
            "postal_code": "83440",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Rexburg, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.