=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144803321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION SPECIALISTS OF IDAHO PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2021
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4207 CLOCK TOWER AVE STE 102
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-5236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-510-5150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16670 BOEHNER RD
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-9224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-440-4966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DARREN HEINER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 208-440-5953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------