Provider Demographics
NPI:1699862805
Name:EYECENTER PA
Entity type:Organization
Organization Name:EYECENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-324-4363
Mailing Address - Street 1:201 SOUTH LINCOLN
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2624
Mailing Address - Country:US
Mailing Address - Phone:208-324-4363
Mailing Address - Fax:208-324-8948
Practice Address - Street 1:201 SOUTH LINCOLN
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2624
Practice Address - Country:US
Practice Address - Phone:208-324-4363
Practice Address - Fax:208-324-8948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYECENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-07
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP7637OtherTRAVELERS RR MEDICARE GRP
CP7637OtherTRAVELERS RR MEDICARE GRP
1371252Medicare ID - Type Unspecified