Provider Demographics
NPI:1104957612
Name:EYE CLINIC OF SANDPOINT PA
Entity type:Organization
Organization Name:EYE CLINIC OF SANDPOINT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-263-8501
Mailing Address - Street 1:307 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1201
Mailing Address - Country:US
Mailing Address - Phone:208-263-8501
Mailing Address - Fax:
Practice Address - Street 1:307 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1201
Practice Address - Country:US
Practice Address - Phone:208-263-8501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0377150001OtherNORIDIAN DMERC SUPPLIER