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General NPI Number Information
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NPI Number | 1598876997
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Entity Type | Organization
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Legal Business Name | MADISON CLINIC OPTOMETRY, P.C.
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 11/28/2007
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Provider Practice Location Address
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Address Line | 244 E MAIN ST
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City | REXBURG
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State | ID
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Zip | 83440-2022
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Country | US
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Telephone | 208-359-1880
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Fax | 208-359-2025
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Provider Business Mailing Address
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Address Line | 244 E MAIN ST
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City | REXBURG
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State | ID
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Zip | 83440-2022
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Country | US
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Telephone | 208-359-1880
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Fax | 208-359-2025
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DALLIN HEINER
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Credential | O.D.
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Telephone | 208-359-1880
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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 |
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License Number State |
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