Provider Demographics
NPI:1467646265
Name:EAGLE VISION CENTER PC
Entity Type:Organization
Organization Name:EAGLE VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:GALBRAITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-356-6911
Mailing Address - Street 1:74 E 1ST S
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1936
Mailing Address - Country:US
Mailing Address - Phone:208-356-6911
Mailing Address - Fax:208-356-3185
Practice Address - Street 1:74 E 1ST S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1936
Practice Address - Country:US
Practice Address - Phone:208-356-6911
Practice Address - Fax:208-356-3185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807725600Medicaid
ID807725600Medicaid
WY1590017Medicare PIN