Provider Demographics
NPI:1003873852
Name:VISION QUEST MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:VISION QUEST MEDICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-377-3937
Mailing Address - Street 1:5680 W GAGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1326
Mailing Address - Country:US
Mailing Address - Phone:208-377-3937
Mailing Address - Fax:208-377-9455
Practice Address - Street 1:5680 W GAGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1326
Practice Address - Country:US
Practice Address - Phone:208-377-3937
Practice Address - Fax:208-377-9455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100002152W00000X
IDODP100417152W00000X
IDO-0860207W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807072200Medicaid
ID807072300Medicaid
ID807072200Medicaid
IDCD8014Medicare PIN
ID807072200Medicaid