Provider Demographics
NPI:1306967120
Name:JOHN T RIETZ
Entity type:Organization
Organization Name:JOHN T RIETZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-746-3626
Mailing Address - Street 1:1616 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4005
Mailing Address - Country:US
Mailing Address - Phone:208-746-3626
Mailing Address - Fax:208-746-1636
Practice Address - Street 1:1616 19TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4005
Practice Address - Country:US
Practice Address - Phone:208-746-3626
Practice Address - Fax:208-746-1636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002674300Medicaid
WA2012219Medicaid
ID0268550001Medicare NSC
WA2012219Medicaid
ID1373333Medicare PIN