Healthcare Provider Details

I. General information

NPI: 1588039127
Provider Name (Legal Business Name): DIAMOND PEAK IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N 2ND E
REXBURG ID
83440-5131
US

IV. Provider business mailing address

PO BOX 158
REXBURG ID
83440-0158
US

V. Phone/Fax

Practice location:
  • Phone: 208-497-6406
  • Fax: 208-359-3007
Mailing address:
  • Phone: 208-497-6406
  • Fax: 208-359-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-959
License Number StateID

VIII. Authorized Official

Name: WADE DEMORDAUNT
Title or Position: OWNER
Credential: O.D.
Phone: 925-222-1957