Healthcare Provider Details

I. General information

NPI: 1629615158
Provider Name (Legal Business Name): BLUEBIRD FAMILY EYE CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N MERIDIAN ST STE A
BLACKFOOT ID
83221-4936
US

IV. Provider business mailing address

720 N MERIDIAN ST STE A
BLACKFOOT ID
83221-4936
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-7274
  • Fax: 208-785-7274
Mailing address:
  • Phone: 208-785-7274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: CODY JONES
Title or Position: OWNER
Credential: OD
Phone: 208-785-7274