Provider Demographics
NPI:1205201050
Name:EAST IDAHO SURGICAL ASSISTING, LLC
Entity Type:Organization
Organization Name:EAST IDAHO SURGICAL ASSISTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:214-227-2457
Mailing Address - Street 1:1435 SCORPIUS DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-1805
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID151909246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty