Provider Demographics
NPI:1134299928
Name:WESTSIDE EYECARE INC
Entity Type:Organization
Organization Name:WESTSIDE EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-529-4333
Mailing Address - Street 1:1689 PANCHERI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3041
Mailing Address - Country:US
Mailing Address - Phone:208-529-4333
Mailing Address - Fax:208-529-4366
Practice Address - Street 1:1689 PANCHERI DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3041
Practice Address - Country:US
Practice Address - Phone:208-529-4333
Practice Address - Fax:208-529-4366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807631000Medicaid
IDV00703Medicare UPIN
ID1369995Medicare PIN
ID5869680001Medicare NSC