1093911133 NPI number — EYE CLINIC OF IDAHO FALLS,PA

Table of content: (NPI 1093911133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093911133 NPI number — EYE CLINIC OF IDAHO FALLS,PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CLINIC OF IDAHO FALLS,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:
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:
1093911133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83403-2410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-529-3937
Provider Business Mailing Address Fax Number:
208-524-4380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 S HOLMES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-4751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-3937
Provider Business Practice Location Address Fax Number:
208-524-4380
Provider Enumeration Date:
06/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
208-529-3937

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  M3793 , 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: 00240930 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1205974136 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 003572200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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