1881781094 NPI number — EYECENTER PA

Table of content: KATE MUNSON RDN, LD (NPI 1548650674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881781094 NPI number — EYECENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYECENTER PA
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:
6
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:
1881781094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
844 SHOSHONE ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83301-6336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-734-9800
Provider Business Mailing Address Fax Number:
208-734-9433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
844 SHOSHONE ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-6336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-9800
Provider Business Practice Location Address Fax Number:
208-734-9433
Provider Enumeration Date:
10/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRILL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER OPTOMETRIST
Authorized Official Telephone Number:
208-734-9800

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CP7637 . This is a "TRAVELERS RR MEDICARE GRP" identifier . This identifiers is of the category "OTHER".




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