Provider Demographics
NPI:1447811740
Name:EAST IDAHO AUDIOLOGY LLC
Entity type:Organization
Organization Name:EAST IDAHO AUDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-6335
Mailing Address - Street 1:527 RIGBY LAKE DR STE C
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5117
Mailing Address - Country:US
Mailing Address - Phone:208-522-6335
Mailing Address - Fax:208-522-0550
Practice Address - Street 1:527 RIGBY LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5117
Practice Address - Country:US
Practice Address - Phone:208-522-6335
Practice Address - Fax:208-522-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1265969406OtherAUDIOLOGY