Provider Demographics
NPI:1154690923
Name:GEM STATE FAMILY EYECARE, P.C.
Entity type:Organization
Organization Name:GEM STATE FAMILY EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-345-6886
Mailing Address - Street 1:3815 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5221
Mailing Address - Country:US
Mailing Address - Phone:208-345-6886
Mailing Address - Fax:208-345-6686
Practice Address - Street 1:3815 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5221
Practice Address - Country:US
Practice Address - Phone:208-345-6886
Practice Address - Fax:208-345-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100213152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty