Healthcare Provider Details

I. General information

NPI: 1265026660
Provider Name (Legal Business Name): JOHN PETER IDEMA BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S RIVER ST STE B
HAILEY ID
83333-8436
US

IV. Provider business mailing address

221 S RIVER ST STE B
HAILEY ID
83333-8436
US

V. Phone/Fax

Practice location:
  • Phone: 208-788-0296
  • Fax: 208-994-0897
Mailing address:
  • Phone: 208-788-0296
  • Fax: 208-994-0897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-2962
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: