Healthcare Provider Details

I. General information

NPI: 1407984925
Provider Name (Legal Business Name): DREW C DAYTON CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 E. MAIN ST.
MIDDLETON ID
83644-5502
US

IV. Provider business mailing address

622 E. MAIN ST.
MIDDLETON ID
83644-5502
US

V. Phone/Fax

Practice location:
  • Phone: 208-585-9500
  • Fax: 208-585-9497
Mailing address:
  • Phone: 208-585-9500
  • Fax: 208-585-9497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-823
License Number StateID

VIII. Authorized Official

Name: DREW C DAYTON
Title or Position: PRESIDENT OWNER
Credential: O.D.
Phone: 208-585-9500