Basic Information
| Provider Information | |||||||||
| NPI: | 1871643585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOLLINGSHEAD EYE CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837066644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837066644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | PENNOW | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2083368700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODP100159 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | M6436 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 805858400 | 05 | ID | MEDICAID | 805858500 | 05 | ID | MEDICAID |