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General NPI Number Information
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NPI Number | 1629427372
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Entity Type | Organization
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Legal Business Name | HAYDEN VISION CENTER
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Dates
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Enumeration Date | 06/03/2016
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Last Update Date | 06/03/2016
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Provider Practice Location Address
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Address Line | 8445 N GOVERNMENT WAY
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City | HAYDEN
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State | ID
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Zip | 83835-9280
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Country | US
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Telephone | 208-772-3208
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Fax |
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Provider Business Mailing Address
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Address Line | 8445 N GOVERNMENT WAY
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City | HAYDEN
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State | ID
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Zip | 83835-9280
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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 | OPTOMETRIST
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Name | ROBERT SORENSEN
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Credential | O.D.
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Telephone | 208-772-3208
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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 - 100363
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License Number State | ID
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