Provider Demographics
NPI:1225227879
Name:MOUNTAIN VISION EYE CARE
Entity Type:Organization
Organization Name:MOUNTAIN VISION EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-265-7965
Mailing Address - Street 1:514 OAK ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1480
Mailing Address - Country:US
Mailing Address - Phone:208-265-7965
Mailing Address - Fax:208-265-4510
Practice Address - Street 1:514 OAK ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1480
Practice Address - Country:US
Practice Address - Phone:208-265-7965
Practice Address - Fax:208-265-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1377695Medicare PIN
IDU90481Medicare UPIN