Provider Demographics
NPI:1548786098
Name:ADA VISION CENTER EAST PLLC
Entity Type:Organization
Organization Name:ADA VISION CENTER EAST PLLC
Other - Org Name:PAUL BIGELOW OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
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:208-318-3937
Mailing Address - Street 1:1617 E LENZ LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8340
Mailing Address - Country:US
Mailing Address - Phone:208-343-1512
Mailing Address - Fax:
Practice Address - Street 1:230 W MALLARD DR STE A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3995
Practice Address - Country:US
Practice Address - Phone:208-342-4841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty