1306983655 NPI number — GRAND TETON EYE & OPTICAL

Table of content: (NPI 1306983655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306983655 NPI number — GRAND TETON EYE & OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND TETON EYE & OPTICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306983655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTOR
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83455-0613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-787-2088
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 BUFFALO WAY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83002-8460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-733-4905
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
LEWIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-787-2088

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ODP-100010 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)