Provider Demographics
NPI:1154616258
Name:DSM OPTOMETRY LLC
Entity type:Organization
Organization Name:DSM OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-525-8964
Mailing Address - Street 1:652 MILL STREAM ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5385
Mailing Address - Country:US
Mailing Address - Phone:208-821-0016
Mailing Address - Fax:208-524-6562
Practice Address - Street 1:2300 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6504
Practice Address - Country:US
Practice Address - Phone:208-525-8964
Practice Address - Fax:208-524-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100185152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1760619365OtherNPI
ID808388100Medicaid
ID1594504Medicare UPIN