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General NPI Number Information
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NPI Number | 1295006039
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Entity Type | Organization
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Legal Business Name | HANSON GROUP LLC
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Dates
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Enumeration Date | 01/25/2012
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Last Update Date | 04/25/2012
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Provider Practice Location Address
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Address Line | 24 E MAIN ST
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City | REXBURG
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State | ID
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Zip | 83440-1927
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Country | US
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Telephone | 208-356-0881
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 547
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City | REXBURG
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State | ID
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Zip | 83440-0547
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DOUGLASS E HANSON
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Credential | ODP
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Telephone | 208-356-0881
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-703
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License Number State | ID
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