Basic Information
| Provider Information | |||||||||
| NPI: | 1083674196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISION CARE CENTER OF IDAHO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3071 E FRANKLIN RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082881400 | ||||||||
| FaxNumber: | 2088550104 | ||||||||
| Practice Location | |||||||||
| Address1: | 3071 E FRANKLIN RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082881400 | ||||||||
| FaxNumber: | 2088550104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCHUGH | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2082881400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000010029517 | 01 | ID | BLUE SHILED | OTHER | FIRST HEALTH CCN | 01 | ID | 2090664 | OTHER | 04101 | 01 | ID | BLUE CROSS | OTHER | 805861000 | 05 | ID | MEDICAID |