Organization
EASTERN IDAHO FOOT CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JERRY D. COOPER D.P.M. (OWNER)
(208) 523-2928
Entity
Organization
Contact information
Practice address
2565 CHANNING WAY, IDAHO FALLS, ID 83404-7516
(208) 523-2928
(208) 523-2962
Mailing address
2565 CHANNING WAY, IDAHO FALLS, ID 83404-7516
(208) 523-2928
(208) 523-2962
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
P126
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001393600
—
ID
Enumeration date
11/17/2009
Last updated
11/17/2009
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