=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326656356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON KEITH HOUSLEY OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2020
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 JAFER CT
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-5587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-529-2700
-----------------------------------------------------
Fax | 208-529-0873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 N MERIDIAN ST STE A
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-4936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP-100513
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------