Healthcare Provider Details

I. General information

NPI: 1629716717
Provider Name (Legal Business Name): ELIAS R LINES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 BOND AVE STE B
REXBURG ID
83440-3503
US

IV. Provider business mailing address

1236 BOND AVE STE B
REXBURG ID
83440-3503
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-4600
  • Fax: 208-552-7521
Mailing address:
  • Phone: 208-522-4600
  • Fax: 208-552-7521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1271657
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: