Organization
IDAHO EYE CENTER PA
Active
Organization
IDAHO EYE CENTER PA
Active
Parent organization
IDAHO EYE CENTER, PA
Organization subpart
Yes
Provider details
NPI number
Legal business name
IDAHO EYE CENTER, PA
Authorized official
DR. BRADLEY P GARDNER MD (SENIOR VICE PRESIDENT)
(208) 524-2025
Entity
Organization
Contact information
Practice address
2025 E 17TH ST, IDAHO FALLS, ID 83404
(208) 524-2025
(208) 529-1924
Mailing address
2025 E 17TH ST, IDAHO FALLS, ID 83404
(208) 524-2025
(208) 529-1924
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
84434
BLUE CROSS
ID
01
—
8C626
BLUE CROSS
ID
01
—
8E837
BLUE CROSS
ID
01
—
8F876
BLUE CROSS
ID
Enumeration date
12/21/2006
Last updated
08/20/2008
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