Organization
EYEDAHO OPTOMETRIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TREVOR DICKSON OD (OWNER)
(208) 709-5371
Entity
Organization
Contact information
Practice address
500 S UTAH AVE, IDAHO FALLS, ID 83402-3305
(208) 528-8643
Mailing address
500 S UTAH AVE, IDAHO FALLS, ID 83402-3305
(208) 528-8643
(208) 528-7243
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
IDTPID015646
—
ID
Enumeration date
09/20/2021
Last updated
09/20/2021
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