Healthcare Provider Details

I. General information

NPI: 1891290235
Provider Name (Legal Business Name): EMERALD OPTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W EMERALD ST STE 105
BOISE ID
83704-5003
US

IV. Provider business mailing address

7447 W EMERALD ST STE 105
BOISE ID
83704-5003
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-1642
  • Fax: 208-378-4179
Mailing address:
  • Phone: 208-322-1642
  • Fax: 208-378-4179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100277
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: PAUL BINGHAM
Title or Position: CEO/OPTOMETRIST
Credential: OD
Phone: 208-280-9762