Provider Demographics
NPI:1225365992
Name:EASTERN IDAHO FOOT CLINIC
Entity Type:Organization
Organization Name:EASTERN IDAHO FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-523-2928
Mailing Address - Street 1:2565 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7516
Mailing Address - Country:US
Mailing Address - Phone:208-523-2928
Mailing Address - Fax:208-523-2962
Practice Address - Street 1:2565 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7516
Practice Address - Country:US
Practice Address - Phone:208-523-2928
Practice Address - Fax:208-523-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP126332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001393600Medicaid
IDT44264Medicare UPIN