=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801001979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUCE W HAMERL O D P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8300 W OVERLAND RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-1639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-321-9082
-----------------------------------------------------
Fax | 208-321-9179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3384 S COLERIDGE PL
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-5584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-321-9082
-----------------------------------------------------
Fax | 208-321-9179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRUCE HAMERL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 208-321-9082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP-847
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------