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General NPI Number Information
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NPI Number | 1467646265
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Entity Type | Organization
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Legal Business Name | EAGLE VISION CENTER PC
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 74 E 1ST S
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City | REXBURG
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State | ID
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Zip | 83440-1936
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Country | US
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Telephone | 208-356-6911
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Fax | 208-356-3185
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Provider Business Mailing Address
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Address Line | 74 E 1ST S
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City | REXBURG
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State | ID
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Zip | 83440-1936
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Country | US
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Telephone | 208-356-6911
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Fax | 208-356-3185
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Authorized Official
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Title or Position | DOCTOR
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Name | SHAWN TAYLOR GALBRAITH
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Credential | OD
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Telephone | 208-356-6911
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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 | ODP100035
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License Number State | ID
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