Provider Demographics
NPI:1154418366
Name:EYECENTER PA
Entity type:Organization
Organization Name:EYECENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SNAPP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-788-4120
Mailing Address - Street 1:14 EAST CROY
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8407
Mailing Address - Country:US
Mailing Address - Phone:208-788-4120
Mailing Address - Fax:208-788-3571
Practice Address - Street 1:14 EAST CROY
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8407
Practice Address - Country:US
Practice Address - Phone:208-788-4120
Practice Address - Fax:208-788-3571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYECENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-07
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP7637OtherTRAVELERS RR MEDICARE GRP
0392220002Medicare NSC
1375819Medicare ID - Type Unspecified