Provider Demographics
NPI:1093982217
Name:OREGON TRAIL EYE CARE, PC
Entity Type:Organization
Organization Name:OREGON TRAIL EYE CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-547-0000
Mailing Address - Street 1:152 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1441
Mailing Address - Country:US
Mailing Address - Phone:208-547-0000
Mailing Address - Fax:208-547-0004
Practice Address - Street 1:152 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1441
Practice Address - Country:US
Practice Address - Phone:208-547-0000
Practice Address - Fax:208-547-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100116152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8076769Medicaid
IDV11255Medicare UPIN
ID8076769Medicaid