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General NPI Number Information
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NPI Number | 1285376558
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Entity Type | Organization
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Legal Business Name | GRANGE OPHTHALMOLOGY, PLLC
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Dates
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Enumeration Date | 04/08/2022
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Last Update Date | 08/15/2023
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Provider Practice Location Address
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Address Line | 450 W STATE ST STE 250
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City | EAGLE
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State | ID
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Zip | 83616-6974
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Country | US
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Telephone | 208-506-7966
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Fax | 208-277-3857
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Provider Business Mailing Address
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Address Line | 450 W STATE ST STE 250
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City | EAGLE
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State | ID
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Zip | 83616-6974
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Country | US
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Telephone | 208-506-7966
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Fax | 208-277-3857
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LAURA RAE NOLDER
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Credential |
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Telephone | 208-989-7151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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