MEDICARE: STATE OF IDAHO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WL0500X	Low Vision Rehabilitation Optometrist

General Provider Information

NPI Number	:	1801833454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF IDAHO

Provider Business Mailing Address
First Line	:	120 S COLE RD
Second Line	:	SUITE 120 - BLDG 3
City	:	BOISE
State	:	ID
Zip	:	83709-0932
Country	:	US
Telephone Number	:	208-334-3220
Fax Number	:	208-334-2963

Provider Business Practice Location Address
First Line	:	120 S COLE RD
Second Line	:	SUITE 120 - BLDG 3
City	:	BOISE
State	:	ID
Zip	:	83709-0932
Country	:	US
Telephone Number	:	208-334-3220
Fax Number	:	208-334-2963

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. ANGELA ROAN
Credential	:
Telephone Number	:	208-334-3220

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	08/22/2020

Similar Medicare Providers

1770417313 — EMMA STILES ST CLAIR
Practice Location Address:

148 S COLE RD
BOISE, ID
83709-0932

Practice Phone: 208-683-8320
Practice Fax:

1639748494 — KENDRA RENAY CARSON LCPC
Practice Location Address:

148 S COLE RD
BOISE, ID
83709-0932

Practice Phone: 208-683-8320
Practice Fax:

1225961741 — JAMES A LOPEZ
Practice Location Address:

148 S COLE RD
BOISE, ID
83709-0932

Practice Phone: 208-683-8320
Practice Fax: 208-969-8380

1346236650 — HOME LIVING SERVICES, INC
Practice Location Address:

106 S COLE RD
BOISE, ID
83709-0932

Practice Phone: 208-376-6810
Practice Fax: 208-376-6899

1194844167 — MR. ERIC A. BROWN MASSAGE THERAPIST
Practice Location Address:

166 S COLE RD
BOISE, ID
83709-0932

Practice Phone: 208-484-6605
Practice Fax: 208-378-2845

1750576955 — HOME LIVING SERVICES
Practice Location Address:

106 S COLE RD
BOISE, ID
83709-0932

Practice Phone: 208-376-6810
Practice Fax: 208-376-6899

Directions to “STATE OF IDAHO ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.