1528494465 NPI number — IDAHO EYE PROS IDAHO FALLS LLC

Table of content: (NPI 1528494465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528494465 NPI number — IDAHO EYE PROS IDAHO FALLS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO EYE PROS IDAHO FALLS 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:
1528494465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3485 N COLE RD UNIT 45479
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:
83711-1095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-297-7019
Provider Business Mailing Address Fax Number:
208-297-7518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2990 S 25TH E
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:
83404-6515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-535-2604
Provider Business Practice Location Address Fax Number:
208-522-0861
Provider Enumeration Date:
09/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GEORGE
Authorized Official First Name:
LAUREL
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNT MANAGER
Authorized Official Telephone Number:
208-954-9106

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: 20006642 . This is a "PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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