Healthcare Provider Details

I. General information

NPI: 1649266040
Provider Name (Legal Business Name): RICK G LUNDGREN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MICHIGAN AVE.
OROFINO ID
83544-9066
US

IV. Provider business mailing address

PO BOX 147
OROFINO ID
83544-0147
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-4814
  • Fax: 208-476-3921
Mailing address:
  • Phone: 208-476-4814
  • Fax: 208-476-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-729
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: