Provider Demographics
NPI:1083674196
Name:VISION CARE CENTER OF IDAHO LLC
Entity Type:Organization
Organization Name:VISION CARE CENTER OF IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCHUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-288-1400
Mailing Address - Street 1:3071 E FRANKLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2376
Mailing Address - Country:US
Mailing Address - Phone:208-288-1400
Mailing Address - Fax:208-855-0104
Practice Address - Street 1:3071 E FRANKLIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2376
Practice Address - Country:US
Practice Address - Phone:208-288-1400
Practice Address - Fax:208-855-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010029517OtherBLUE SHILED
IDFIRST HEALTH CCNOther2090664
ID04101OtherBLUE CROSS
ID805861000Medicaid
ID805861000Medicaid