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General NPI Number Information
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NPI Number | 1629962865
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Entity Type | Organization
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Legal Business Name | JUSTIN T HEINTZ O D LLC
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Dates
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Enumeration Date | 06/04/2025
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 665 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5596
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Country | US
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Telephone | 541-231-0668
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Fax |
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Provider Business Mailing Address
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Address Line | 1569 N 885 E
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City | SHELLEY
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State | ID
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Zip | 83274-3201
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Country | US
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Telephone | 541-231-0668
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Fax |
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Authorized Official
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Title or Position | BILLING DEPT MANAGER
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Name | DIANA LEE COOPER
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Credential |
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Telephone | 541-740-8021
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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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