Healthcare Provider Details

I. General information

NPI: 1841332343
Provider Name (Legal Business Name): LITTLE MO'S OPTICAL BOUTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 LINCOLN WAY
COEURD ALENE ID
83814
US

IV. Provider business mailing address

1720 LINCOLN WAY
COEURD ALENE ID
83814
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-4011
  • Fax: 208-664-4022
Mailing address:
  • Phone: 208-664-4011
  • Fax: 208-664-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateID

VIII. Authorized Official

Name: LYNN C ERICKSON
Title or Position: OWNER
Credential: OPTICIAN
Phone: 208-664-4011