Provider Demographics
NPI:1386811404
Name:IDAHO FALLS VISION CENTER CHARTERED
Entity type:Organization
Organization Name:IDAHO FALLS VISION CENTER CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAUL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-268-8496
Mailing Address - Street 1:600 CASCADE MALL DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-3260
Mailing Address - Country:US
Mailing Address - Phone:360-757-5513
Mailing Address - Fax:
Practice Address - Street 1:20231 209TH AVE SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-9371
Practice Address - Country:US
Practice Address - Phone:360-757-5513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1570TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT81731Medicare UPIN
WAAB36653Medicare PIN