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General NPI Number Information
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NPI Number | 1275808750
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Entity Type | Organization
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Legal Business Name | EAST IDAHO EAR NOSE THROAT-FACIAL PLASTIC SURGERY PA
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Dates
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Enumeration Date | 03/15/2012
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Last Update Date | 04/04/2024
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Provider Practice Location Address
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Address Line | 3446 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8262
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Country | US
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Telephone | 208-522-6335
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Fax | 208-522-0550
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Provider Business Mailing Address
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Address Line | 3446 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8262
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Country | US
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Telephone | 208-522-6335
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Fax | 208-522-0550
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD GARRETT LEE
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Credential | MD
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Telephone | 208-522-6335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YP0228X
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Taxonomy Name | Pediatric Otolaryngology Physician
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License Number | M10574
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License Number State | ID
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