Healthcare Provider Details

I. General information

NPI: 1912114273
Provider Name (Legal Business Name): EASTERN IDAHO PUBLIC HEALTH DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 HOLLIPARK DR
IDAHO FALLS ID
83401-6217
US

IV. Provider business mailing address

1250 HOLLIPARK DR
IDAHO FALLS ID
83401-6217
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-0310
  • Fax: 208-525-7063
Mailing address:
  • Phone: 208-522-0310
  • Fax: 208-525-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD-3456
License Number StateID

VIII. Authorized Official

Name: MR. RICHARD HORNE
Title or Position: DIRECTOR
Credential:
Phone: 208-522-0310