Healthcare Provider Details

I. General information

NPI: 1508742909
Provider Name (Legal Business Name): HEROIC DIABETES INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4214 N AMBERCREEK AVE
MERIDIAN ID
83646-7019
US

IV. Provider business mailing address

1302 MEADOWVIEW AVE
REXBURG ID
83440-5079
US

V. Phone/Fax

Practice location:
  • Phone: 208-821-4136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JAREN SMITH
Title or Position: PRESIDENT
Credential: RN, BSN
Phone: 208-821-4136