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General NPI Number Information
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NPI Number | 1588039127
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Entity Type | Organization
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Legal Business Name | DIAMOND PEAK IDAHO
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Dates
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Enumeration Date | 12/08/2015
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Last Update Date | 02/04/2016
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Provider Practice Location Address
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Address Line | 1450 N 2ND E
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City | REXBURG
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State | ID
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Zip | 83440-5131
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Country | US
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Telephone | 208-497-6406
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Fax | 208-359-3007
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Provider Business Mailing Address
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Address Line | PO BOX 158
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City | REXBURG
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State | ID
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Zip | 83440-0158
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Country | US
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Telephone | 208-497-6406
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Fax | 208-359-3007
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Authorized Official
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Title or Position | OWNER
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Name | WADE DEMORDAUNT
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Credential | O.D.
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Telephone | 925-222-1957
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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 | ODP-959
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License Number State | ID
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