=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285705772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIELSON EYECARE PROFESSIONALS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1715 S WELLS AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-898-0304
-----------------------------------------------------
Fax | 208-898-0380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2320 E GALA ST SUITE 400
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-7091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-898-0304
-----------------------------------------------------
Fax | 208-898-0380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING COORDINATOR
-----------------------------------------------------
Name | APRIL MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-898-0304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP100015
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------