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General NPI Number Information
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NPI Number | 1225365992
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Entity Type | Organization
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Legal Business Name | EASTERN IDAHO FOOT CLINIC
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Dates
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Enumeration Date | 11/17/2009
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Last Update Date | 11/17/2009
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Provider Practice Location Address
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Address Line | 2565 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7516
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Country | US
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Telephone | 208-523-2928
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Fax | 208-523-2962
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Provider Business Mailing Address
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Address Line | 2565 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7516
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Country | US
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Telephone | 208-523-2928
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Fax | 208-523-2962
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRY D. COOPER
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Credential | D.P.M.
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Telephone | 208-523-2928
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | P126
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License Number State | ID
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