Healthcare Provider Details

I. General information

NPI: 1962123315
Provider Name (Legal Business Name): TEA OBS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 S EAGLE RD
MERIDIAN ID
83642-6704
US

IV. Provider business mailing address

2620 S EAGLE RD
MERIDIAN ID
83642-6704
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-5151
  • Fax:
Mailing address:
  • Phone: 208-342-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID CROOKE
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-342-5151