Provider Demographics
NPI:1588039127
Name:DIAMOND PEAK IDAHO
Entity Type:Organization
Organization Name:DIAMOND PEAK IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMORDAUNT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:925-222-1957
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0158
Mailing Address - Country:US
Mailing Address - Phone:208-497-6406
Mailing Address - Fax:208-359-3007
Practice Address - Street 1:1450 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5131
Practice Address - Country:US
Practice Address - Phone:208-497-6406
Practice Address - Fax:208-359-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-959152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z164411Medicare PIN
U65669Medicare UPIN