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General NPI Number Information
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NPI Number | 1154616258
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Entity Type | Organization
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Legal Business Name | DSM OPTOMETRY LLC
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Dates
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Enumeration Date | 06/16/2011
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Last Update Date | 06/16/2011
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Provider Practice Location Address
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Address Line | 2300 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6504
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Country | US
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Telephone | 208-525-8964
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Fax | 208-524-6562
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Provider Business Mailing Address
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Address Line | 652 MILL STREAM ST
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City | REXBURG
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State | ID
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Zip | 83440-5385
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Country | US
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Telephone | 208-821-0016
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Fax | 208-524-6562
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Authorized Official
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Title or Position | OWNER/DR.
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Name | DR. DAMON SCOTT MORTENSEN
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Credential | OD
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Telephone | 208-525-8964
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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-100185
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License Number State | ID
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