MEDICARE: LANCE F OUGH O.D.

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	152WC0802X	Corneal and Contact Management Optometrist	ODP 100038	ID

General Provider Information

NPI Number	:	1821082470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE F OUGH O.D.

Provider Business Mailing Address
First Line	:	20 QUAIL LN
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83716-3114
Country	:	US
Telephone Number	:	208-343-0046
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 N MILWAUKEE ST
Second Line	:	#2153
City	:	BOISE
State	:	ID
Zip	:	83704-9123
Country	:	US
Telephone Number	:	208-322-1642
Fax Number	:	208-378-4179

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	07/08/2007

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