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General NPI Number Information
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NPI Number | 1255401436
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Entity Type | Organization
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Legal Business Name | IDAHO EYELID & FACIAL PLASTIC SURGERY , PLLC
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 04/03/2020
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Provider Practice Location Address
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Address Line | 111 W MAIN ST STE 200
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City | BOISE
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State | ID
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Zip | 83702-7308
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Country | US
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Telephone | 208-344-3220
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Fax | 208-344-0461
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Provider Business Mailing Address
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Address Line | 111 W MAIN ST STE 200
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City | BOISE
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State | ID
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Zip | 83702-7308
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Country | US
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Telephone | 208-344-3220
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Fax | 208-344-0461
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK J BOERNER
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Credential | M.D.
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Telephone | 208-344-3220
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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