Provider Demographics
NPI:1992808182
Name:BIG BLUE OPTICS, PC
Entity type:Organization
Organization Name:BIG BLUE OPTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-433-1410
Mailing Address - Street 1:1410 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3706
Mailing Address - Country:US
Mailing Address - Phone:208-433-1410
Mailing Address - Fax:208-433-1403
Practice Address - Street 1:1410 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3706
Practice Address - Country:US
Practice Address - Phone:208-433-1410
Practice Address - Fax:208-433-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU94555Medicare UPIN
ID1594386Medicare ID - Type UnspecifiedMEDICARE