Healthcare Provider Details

I. General information

NPI: 1780641902
Provider Name (Legal Business Name): VISION QUEST MEDICAL CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 W GAGE ST
BOISE ID
83706-1326
US

IV. Provider business mailing address

5680 W GAGE ST
BOISE ID
83706-1326
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-3937
  • Fax: 208-377-9455
Mailing address:
  • Phone: 208-377-3937
  • Fax: 208-377-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JACOB A MONG
Title or Position: PRESIDENT
Credential: DO
Phone: 208-377-3937