Provider Demographics
NPI:1124684485
Name:MAPLE GROVE EYECARE PC
Entity type:Organization
Organization Name:MAPLE GROVE EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/OPHTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-687-1715
Mailing Address - Street 1:8955 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1673
Mailing Address - Country:US
Mailing Address - Phone:208-344-7944
Mailing Address - Fax:208-343-4676
Practice Address - Street 1:8955 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-344-7944
Practice Address - Fax:208-343-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1184885345Medicaid