Provider Demographics
NPI:1801997234
Name:INTERMOUNTAIN OCULAR PROSTHETICS, INC.
Entity type:Organization
Organization Name:INTERMOUNTAIN OCULAR PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:MURANO
Authorized Official - Suffix:II
Authorized Official - Credentials:BCO, BADO
Authorized Official - Phone:208-378-8200
Mailing Address - Street 1:2308 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3152
Mailing Address - Country:US
Mailing Address - Phone:208-378-8200
Mailing Address - Fax:
Practice Address - Street 1:2308 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3152
Practice Address - Country:US
Practice Address - Phone:208-378-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113182600Medicaid
ID805051400Medicaid
OR278130Medicaid
MT0005600854Medicaid
MT0005600854Medicaid