Healthcare Provider Details

I. General information

NPI: 1487128823
Provider Name (Legal Business Name): ARTISAN PEDIATRIC EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7960 W RIFLEMAN ST STE 110
BOISE ID
83704-9064
US

IV. Provider business mailing address

152 N AL FRESCO PL
BOISE ID
83712-7599
US

V. Phone/Fax

Practice location:
  • Phone: 208-489-1477
  • Fax:
Mailing address:
  • Phone: 208-866-9455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY C JOHNSON
Title or Position: MANAGER
Credential: OD
Phone: 208-489-1477