Healthcare Provider Details

I. General information

NPI: 1457716482
Provider Name (Legal Business Name): BRYCE B. THUESON, O.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 PROFESSIONAL PLZ
REXBURG ID
83440-2047
US

IV. Provider business mailing address

76 PROFESSIONAL PLZ
REXBURG ID
83440-2047
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4585
  • Fax: 208-356-4587
Mailing address:
  • Phone: 208-356-4585
  • Fax: 208-356-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP100014
License Number StateID

VIII. Authorized Official

Name: DR. BRYCE B THUESON
Title or Position: OWNER
Credential: O.D.
Phone: 208-356-4585