Organization
TETON RETINAL INSTITUTE PA
Active
Organization
TETON RETINAL INSTITUTE PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DARRYL G MOFFETT JR. MD (PRESIDENT)
(208) 535-4900
Entity
Organization
Contact information
Practice address
3544 E 17TH ST, STE 105, AMMON, ID 83406-6911
(208) 535-4900
(208) 535-4906
Mailing address
3544 E 17TH ST, STE 105, AMMON, ID 83406-6911
(208) 535-4900
(208) 535-4906
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
M6263
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8G320
BLUE CROSS GROUP
ID
Enumeration date
03/20/2007
Last updated
11/18/2015
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