Provider Demographics
NPI:1174632244
Name:EYECENTER PA
Entity Type:Organization
Organization Name:EYECENTER PA
Other - Org Name:KETCHUM EYECENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRILL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-734-9800
Mailing Address - Street 1:PO BOX 6129
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6129
Mailing Address - Country:US
Mailing Address - Phone:208-726-3363
Mailing Address - Fax:208-726-0138
Practice Address - Street 1:180 1ST AVE N
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-6129
Practice Address - Country:US
Practice Address - Phone:208-726-3363
Practice Address - Fax:208-726-0138
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYECENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-30
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP7637OtherTRAVELERS RR MEDICARE GRP
CP7637OtherTRAVELERS RR MEDICARE GRP
1371254Medicare ID - Type Unspecified