Provider Demographics
NPI:1073814737
Name:CARTER VISION CARE, PLLC
Entity Type:Organization
Organization Name:CARTER VISION CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-713-0104
Mailing Address - Street 1:1157 E PUFFIN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7444
Mailing Address - Country:US
Mailing Address - Phone:208-880-6891
Mailing Address - Fax:
Practice Address - Street 1:1157 E PUFFIN ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7444
Practice Address - Country:US
Practice Address - Phone:208-880-6891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1891789368OtherINDIVIDUAL NPI
ID807254900Medicaid
ID807254900Medicaid