1235255605 NPI number — EAGLE EYE SURGERY AND LASER CENTER LLC

Table of content: (NPI 1235255605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235255605 NPI number — EAGLE EYE SURGERY AND LASER CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE EYE SURGERY AND LASER CENTER 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:
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:
1235255605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1A BURTON HILLS BLVD
Provider Second Line Business Mailing Address:
ATTN: L&C
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-665-1283
Provider Business Mailing Address Fax Number:
615-234-1720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3090 E GENTRY WAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-3548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-288-1600
Provider Business Practice Location Address Fax Number:
208-288-4299
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SNODGRASS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

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: 000010029603 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805834800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04093 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 150695 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490004716 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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