# MOUNTAIN STATES DIABETES RELIEF, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1144783499
- **Authorized official:** KATIE DAVENPORT (PARTNER)
- **Authorized official phone:** (208) 520-2636

## Contact information

- **Practice address:** 4573 E MAJESTIC, IDAHO FALLS, ID 83406
- **Practice address phone:** (208) 520-2636
- **Mailing address:** 4573 E MAJESTIC, IDAHO FALLS, ID 83406
- **Mailing address phone:** (208) 520-2636

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | NULL | Yes |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | — | Yes |

## Other

- **Enumeration date:** 04/12/2019
- **Last updated:** 04/12/2019