Provider Demographics
NPI:1407869589
Name:ADA VISION CENTER P.A.
Entity Type:Organization
Organization Name:ADA VISION CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-336-2020
Mailing Address - Street 1:1333 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5320
Mailing Address - Country:US
Mailing Address - Phone:208-336-2020
Mailing Address - Fax:208-384-5677
Practice Address - Street 1:1333 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5320
Practice Address - Country:US
Practice Address - Phone:208-336-2020
Practice Address - Fax:208-384-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010138576OtherREGENCE BLUE SHIELD
IDV7042OtherBLUE CROSS OF IDAHO
IDU80987Medicaid
ID4529000001Medicare NSC
IDU80987Medicaid
IDV7042OtherBLUE CROSS OF IDAHO