Provider Demographics
NPI:1336624030
Name:BINGHAM FAMILY VISION, LLC
Entity type:Organization
Organization Name:BINGHAM FAMILY VISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-2210
Mailing Address - Street 1:715 W JUDICIAL ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2036
Mailing Address - Country:US
Mailing Address - Phone:208-785-2210
Mailing Address - Fax:208-785-2216
Practice Address - Street 1:715 W JUDICIAL ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2036
Practice Address - Country:US
Practice Address - Phone:208-785-2210
Practice Address - Fax:208-785-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215120696Medicaid