Healthcare Provider Details

I. General information

NPI: 1477866606
Provider Name (Legal Business Name): IDAHO ALLERGY L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 E SHORE DR SUITE 100
EAGLE ID
83616-5410
US

IV. Provider business mailing address

379 E SHORE DR SUITE 100
EAGLE ID
83616-5410
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-3443
  • Fax: 208-938-3553
Mailing address:
  • Phone: 208-938-3443
  • Fax: 208-938-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberM103
License Number StateID

VIII. Authorized Official

Name: DR. STEPHEN B FRITZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-938-3443