=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629272323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON N HURLEY O.D., PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 10/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 RIGBY LAKE DR STE 301
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-745-0181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 RIGBY LAKE DR STE 301
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-745-0181
-----------------------------------------------------
Fax | 208-745-1121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OD
-----------------------------------------------------
Name | JASON HURLEY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 208-745-0181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP100063
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------