Healthcare Provider Details

I. General information

NPI: 1104316785
Provider Name (Legal Business Name): PEND OREILLE VISION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6132 HIGHWAY 2
PRIEST RIVER ID
83856
US

IV. Provider business mailing address

514 OAK ST STE A
SANDPOINT ID
83864-1480
US

V. Phone/Fax

Practice location:
  • Phone: 208-448-0144
  • Fax: 208-448-0147
Mailing address:
  • Phone: 208-265-7965
  • Fax: 208-265-7905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NATHANEAL HARRELL
Title or Position: OWNER/PRESIDENT
Credential: OD
Phone: 208-265-7965