MEDICARE: SPOONER EYE CARE SC

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	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2200142	OTHER		MEDICA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992773998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPOONER EYE CARE SC

Provider Business Mailing Address
First Line	:	1611 RIVER ST
Second Line	:
City	:	PAYETTE
State	:	ID
Zip	:	83661-2073
Country	:	US
Telephone Number	:	715-520-3414
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 RIVER ST
Second Line	:
City	:	PAYETTE
State	:	ID
Zip	:	83661-2073
Country	:	US
Telephone Number	:	715-520-3414
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. SONDRA KAY SHELLITO
Credential	:
Telephone Number	:	715-520-3606

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	12/10/2019

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Directions to “SPOONER EYE CARE SC ” Practice Location

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