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General NPI Number Information
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NPI Number | 1871643585
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Entity Type | Organization
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Legal Business Name | HOLLINGSHEAD EYE CENTER, PC
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 06/29/2010
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Provider Practice Location Address
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Address Line | 360 E MALLARD DR SUITE 110
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City | BOISE
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State | ID
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Zip | 83706-6644
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Country | US
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Telephone | 208-336-8700
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Fax | 208-426-0902
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Provider Business Mailing Address
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Address Line | 360 E MALLARD DR SUITE 110
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City | BOISE
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State | ID
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Zip | 83706-6644
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Country | US
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Telephone | 208-336-8700
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Fax | 208-426-0902
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Authorized Official
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Title or Position | DIRECTOR
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Name | LOUIS M PENNOW
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Credential | MBA
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Telephone | 208-336-8700
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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 | ODP100159
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | M6436
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License Number State | ID
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