Provider Demographics
NPI:1336981158
Name:AMPLIFY OPTOMETRY OF AMERICA PLLC
Entity type:Organization
Organization Name:AMPLIFY OPTOMETRY OF AMERICA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-552-7323
Mailing Address - Street 1:6125 LUTHER LN # 572
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6202
Mailing Address - Country:US
Mailing Address - Phone:312-608-4584
Mailing Address - Fax:
Practice Address - Street 1:2550 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6507
Practice Address - Country:US
Practice Address - Phone:208-552-7323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty