Healthcare Provider Details

I. General information

NPI: 1770851446
Provider Name (Legal Business Name): PORTER EYECARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 E LINCOLN RD STE B
IDAHO FALLS ID
83401-2128
US

IV. Provider business mailing address

852 E PARRI DR
IDAHO FALLS ID
83401-5626
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-8686
  • Fax: 208-525-8684
Mailing address:
  • Phone: 208-525-8686
  • Fax: 208-525-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberIDP 100113
License Number StateID

VIII. Authorized Official

Name: LISA LIN PORTER
Title or Position: OWNER
Credential: OD
Phone: 208-757-0441