Healthcare Provider Details

I. General information

NPI: 1447811740
Provider Name (Legal Business Name): EAST IDAHO AUDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 RIGBY LAKE DR STE C
RIGBY ID
83442-5117
US

IV. Provider business mailing address

527 RIGBY LAKE DR STE C
RIGBY ID
83442-5117
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-6335
  • Fax: 208-522-0550
Mailing address:
  • Phone: 208-522-6335
  • Fax: 208-522-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355A2700X
TaxonomyAudiology Assistant
License Number
License Number State

VIII. Authorized Official

Name: RICHARD LEE
Title or Position: OWNER
Credential: MD
Phone: 208-522-6335