Provider Demographics
NPI:1528494465
Name:IDAHO EYE PROS IDAHO FALLS LLC
Entity type:Organization
Organization Name:IDAHO EYE PROS IDAHO FALLS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-954-9106
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:208-297-7019
Mailing Address - Fax:208-297-7518
Practice Address - Street 1:2990 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6515
Practice Address - Country:US
Practice Address - Phone:208-535-2604
Practice Address - Fax:208-522-0861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20006642OtherPTAN