Provider Demographics
NPI:1629962865
Name:JUSTIN T HEINTZ O D LLC
Entity type:Organization
Organization Name:JUSTIN T HEINTZ O D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-740-8021
Mailing Address - Street 1:1569 N 885 E
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-3201
Mailing Address - Country:US
Mailing Address - Phone:541-231-0668
Mailing Address - Fax:
Practice Address - Street 1:665 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5596
Practice Address - Country:US
Practice Address - Phone:541-231-0668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-04
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty