Healthcare Provider Details

I. General information

NPI: 1730865056
Provider Name (Legal Business Name): INTERMOUNTAIN EYE AND LASER CENTERS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 E FLAMINGO AVE
NAMPA ID
83687-9203
US

IV. Provider business mailing address

999 N CURTIS RD
BOISE ID
83706-1336
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-2222
  • Fax:
Mailing address:
  • Phone: 208-373-1200
  • Fax: 208-373-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number
License Number State

VIII. Authorized Official

Name: BRENT S BETTS
Title or Position: PARTNER
Credential:
Phone: 801-581-2352