Healthcare Provider Details

I. General information

NPI: 1275808750
Provider Name (Legal Business Name): EAST IDAHO EAR NOSE THROAT-FACIAL PLASTIC SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3446 S 15TH E
IDAHO FALLS ID
83404-8262
US

IV. Provider business mailing address

3446 S 15TH E
IDAHO FALLS ID
83404-8262
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-6335
  • Fax: 208-522-0550
Mailing address:
  • Phone: 208-522-6335
  • Fax: 208-522-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberM10574
License Number StateID

VIII. Authorized Official

Name: DR. RICHARD GARRETT LEE
Title or Position: OWNER
Credential: MD
Phone: 208-522-6335