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Henry's Fork Surgery Center, PLLC

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Company Details

Name: Henry's Fork Surgery Center, PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 24 Mar 2020 (5 years ago)
Financial Date End: 31 Mar 2026
Entity Number: 3818624
Place of Formation: IDAHO
File Number: 704124
ZIP code: 83440
County: Madison County
Principal Address: 23 SAWTELLE AVENUE REXBURG, ID 83440
Mailing Address: PO BOX 6 REXBURG, ID 83440-0006

Agent

Name Role Address
JOSHUA R FULLMER Agent 2200 S 6000 W, REXBURG, ID 83440

Member

Name Role Address Appointed On Resigned On
Kyle G. Thompson Member 2100 PROVIDENCE WAY, IDAHO FALLS, ID 83404 2024-04-05 2024-04-05
Jason G. Hooton Member 2100 PROVIDENCE WAY, IDAHO FALLS, ID 83404 2024-04-05 2024-04-05
Joshua R. Fullmer Member 23 SAWTELLE, REXBURG, ID 83440 2020-07-16 No data
Matthew P. Traynor Member 2100 PROVIDENCE WAY, IDAHO FALLS, ID 83404 2024-04-05 2024-04-05

Unique Entity ID

A UEI is a government-provided number, like a tax ID number, that’s used to identify businesses eligible for federal grants, awards and contracts.

Note: In April 2022, the federal government replaced its old identifier of choice, the Data Universal Numbering System (DUNS) number, with a government-issued UEI. Now all the federal government’s Integrated Award Environment systems use UEI numbers instead of DUNS numbers. So any entity doing business with the federal government must register for a UEI.

Unique Entity ID:
KHH1N9GDYRD1
UEI Expiration Date:
2025-08-02

Business Information

Doing Business As:
HENRY & APOSS FORK SURGERY CENTER PLLC
Activation Date:
2024-08-06
Initial Registration Date:
2023-08-01

National Provider Identifier

NPI Number:
1235768490
Certification Date:
2020-04-30

Authorized Person:

Name:
HOLLY ALLEN
Role:
MANAGER
Phone:

Taxonomy:

Selected Taxonomy:
261QA1903X - Ambulatory Surgical Clinic/Center
Is Primary:
Yes

Contacts:

Fax:
2083591888
Fax:
2083591889

Filing

Filing Name Filing Number Filing date
Annual Report 0006180780 2025-04-02
Annual Report 0005675863 2024-04-05
Annual Report 0005172921 2023-03-31
Annual Report 0004679924 2022-03-31
Annual Report 0004223809 2021-03-31

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Date of last update: 18 May 2025

Sources: Idaho Secretary of State