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General NPI Number Information
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NPI Number | 1316663032
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Entity Type | Organization
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Legal Business Name | GRANGE SURGERY CENTER PLLC
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Dates
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Enumeration Date | 10/14/2022
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Last Update Date | 08/22/2023
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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 |
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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 |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | LANDON GRANGE
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Credential | MD
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Telephone | 208-506-7966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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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 | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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