Healthcare Provider Details

I. General information

NPI: 1518643923
Provider Name (Legal Business Name): INTERMOUNTAIN EYE AND LASER CENTERS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 E RIVERSIDE DR STE 122
EAGLE ID
83616-6865
US

IV. Provider business mailing address

999 N CURTIS RD STE 205
BOISE ID
83706-1316
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-4749
  • Fax:
Mailing address:
  • Phone: 208-373-1200
  • Fax: 208-373-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRENT S BETTS
Title or Position: PARTNER
Credential:
Phone: 801-581-2352