Provider Demographics
NPI:1093851081
Name:COEUR D ALENE OPTICAL, INC.
Entity type:Organization
Organization Name:COEUR D ALENE OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEDE
Authorized Official - Middle Name:KAREN
Authorized Official - Last Name:SINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-2531
Mailing Address - Street 1:1814 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2540
Mailing Address - Country:US
Mailing Address - Phone:208-667-2531
Mailing Address - Fax:208-765-9385
Practice Address - Street 1:1814 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2540
Practice Address - Country:US
Practice Address - Phone:208-667-2531
Practice Address - Fax:208-765-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010014269OtherREGENCE BLUE SHIELD OF ID
ID1590069Medicare NSC
ID000010014269OtherREGENCE BLUE SHIELD OF ID