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General NPI Number Information
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NPI Number | 1023223187
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Entity Type | Organization
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Legal Business Name | ASPEN RIDGE EYE CARE, PLLC
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 05/01/2013
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Provider Practice Location Address
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Address Line | 3456 E 17TH ST SUITE 150
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City | AMMON
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State | ID
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Zip | 83406-6757
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Country | US
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Telephone | 208-528-6900
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Fax | 208-528-6904
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Provider Business Mailing Address
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Address Line | 3456 E 17TH ST SUITE 150
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City | AMMON
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State | ID
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Zip | 83406-6757
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Country | US
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Telephone | 208-528-6900
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Fax | 208-528-6904
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRY D CARLSON
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Credential | O.D.
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Telephone | 208-528-6900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-100104
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License Number State | ID
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