Healthcare Provider Details

I. General information

NPI: 1831490507
Provider Name (Legal Business Name): E JOLENE LUND AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 07/21/2022
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 E 17TH ST STE 119
IDAHO FALLS ID
83404-8046
US

IV. Provider business mailing address

1970 E 17TH ST STE 119
IDAHO FALLS ID
83404-8046
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-3141
  • Fax: 208-542-1112
Mailing address:
  • Phone: 208-522-3141
  • Fax: 208-542-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number5888664-4101
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD-2064
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: