Provider Demographics
NPI:1144783499
Name:MOUNTAIN STATES DIABETES RELIEF, LLC
Entity type:Organization
Organization Name:MOUNTAIN STATES DIABETES RELIEF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-520-2636
Mailing Address - Street 1:4573 E MAJESTIC
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-520-2636
Mailing Address - Fax:
Practice Address - Street 1:4573 E MAJESTIC
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-520-2636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty