1780612499 NPI number — DR. AMANDA LEANNE MOORE-ELCYZYN O.D.

Table of content: SEAN HOSTMEYER MD (NPI 1104210673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780612499 NPI number — DR. AMANDA LEANNE MOORE-ELCYZYN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE-ELCYZYN
Provider First Name:
AMANDA
Provider Middle Name:
LEANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
AMANDA
Provider Other Middle Name:
LEANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780612499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1926 W STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83702-3957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-336-2020
Provider Business Mailing Address Fax Number:
208-384-5677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 W CARPENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-778-2363
Provider Business Practice Location Address Fax Number:
501-778-5329
Provider Enumeration Date:
06/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2566 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: ODP-100499 , 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)

  • Identifier: 49956 . This is a "MEDICARE #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 161893722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".