Healthcare Provider Details

I. General information

NPI: 1801830666
Provider Name (Legal Business Name): REXBURG VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 E 1ST S
REXBURG ID
83440-1966
US

IV. Provider business mailing address

49 E 1ST S PO BOX 577
REXBURG ID
83440-1966
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4444
  • Fax: 208-356-4445
Mailing address:
  • Phone: 208-356-4444
  • Fax: 208-356-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberODP-100403
License Number StateID

VIII. Authorized Official

Name: DR. DARREN HATCH
Title or Position: PARTNER
Credential: OD
Phone: 208-356-4444