Healthcare Provider Details

I. General information

NPI: 1336981158
Provider Name (Legal Business Name): AMPLIFY OPTOMETRY OF AMERICA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 S 25TH E
IDAHO FALLS ID
83404-6507
US

IV. Provider business mailing address

6125 LUTHER LN # 572
DALLAS TX
75225-6202
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-7323
  • Fax:
Mailing address:
  • Phone: 312-608-4584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JERRY NAVE
Title or Position: OWNER
Credential: OD
Phone: 208-552-7323