Healthcare Provider Details

I. General information

NPI: 1215945431
Provider Name (Legal Business Name): EYE CLINIC OF SANDPOINT PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 S 1ST AVE
SANDPOINT ID
83864
US

IV. Provider business mailing address

307 S 1ST AVE
SANDPOINT ID
83864-1201
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-8501
  • Fax: 208-263-9713
Mailing address:
  • Phone: 208-263-8501
  • Fax: 208-263-9713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JASON M PETERSEN
Title or Position: PHYSICIAN-OWNER
Credential: OD
Phone: 208-263-8501