1083674196 NPI number — VISION CARE CENTER OF IDAHO LLC

Table of content: (NPI 1083674196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083674196 NPI number — VISION CARE CENTER OF IDAHO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION CARE CENTER OF IDAHO LLC
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:
1083674196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3071 E FRANKLIN RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-2376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-288-1400
Provider Business Mailing Address Fax Number:
208-855-0104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3071 E FRANKLIN RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-1400
Provider Business Practice Location Address Fax Number:
208-855-0104
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCHUGH
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-288-1400

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010029517 . This is a "BLUE SHILED" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: FIRST HEALTH CCN . This is a "2090664" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 04101 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805861000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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