Organization
DIAMOND PEAK IDAHO
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WADE DEMORDAUNT O.D. (OWNER)
(925) 222-1957
Entity
Organization
Contact information
Practice address
1450 N 2ND E, REXBURG, ID 83440-5131
(208) 497-6406
(208) 359-3007
Mailing address
PO BOX 158, REXBURG, ID 83440-0158
(208) 497-6406
(208) 359-3007
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
ODP-959
ID
Other
Enumeration date
12/08/2015
Last updated
02/04/2016
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