Basic Information
Provider Information | |||||||||
NPI: | 1568179042 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IDEAL OPTION, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5615 DUNBARTON AVE | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993018216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5092221275 | ||||||||
FaxNumber: | 8338887145 | ||||||||
Practice Location | |||||||||
Address1: | 301 SADDLE DR STE G | ||||||||
Address2: |   | ||||||||
City: | HELENA | ||||||||
State: | MT | ||||||||
PostalCode: | 596018026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8775221275 | ||||||||
FaxNumber: | 8338887145 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2022 | ||||||||
LastUpdateDate: | 11/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOWDEN | ||||||||
AuthorizedOfficialFirstName: | SHANNON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTING & CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5095709302 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.