1407869589 NPI number — ADA VISION CENTER P.A.

Table of content: (NPI 1407869589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407869589 NPI number — ADA VISION CENTER P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADA VISION CENTER P.A.
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:
1407869589
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1333 W JEFFERSON 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:
83702-5320
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:
1333 W JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-5320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-336-2020
Provider Business Practice Location Address Fax Number:
208-384-5677
Provider Enumeration Date:
08/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NOBLE
Authorized Official First Name:
TODD
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-336-2020

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: 000010138576 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: V7042 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: U80987 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".