=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265688584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POST FALLS OPTOMETRIC PHYSICIANS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2008
-----------------------------------------------------
Last Update Date | 07/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 W 4TH AVE STE A
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-5089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-773-7434
-----------------------------------------------------
Fax | 208-777-0836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 W 4TH AVE STE A
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-4979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-773-7434
-----------------------------------------------------
Fax | 208-777-0836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SPECIALIST/ CLINIC MANAGER
-----------------------------------------------------
Name | MS. MISSY H DUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-773-7434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP- 100218
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------