Provider Demographics
NPI:1386856284
Name:KOOTENAI VISION, PLLC
Entity Type:Organization
Organization Name:KOOTENAI VISION, PLLC
Other - Org Name:KOOTENAI VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-667-2591
Mailing Address - Street 1:1801 N THIRD ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-667-1591
Mailing Address - Fax:208-676-8574
Practice Address - Street 1:1801 N THIRD ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-667-1591
Practice Address - Fax:208-676-8574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP1029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty