Provider Demographics
NPI:1588847248
Name:ANNS EYEWEAR BOUTIQUE INC
Entity Type:Organization
Organization Name:ANNS EYEWEAR BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:BRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:208-733-1067
Mailing Address - Street 1:691 SHOSHONE ST N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6154
Mailing Address - Country:US
Mailing Address - Phone:208-733-1067
Mailing Address - Fax:
Practice Address - Street 1:691 SHOSHONE ST N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-1067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ601I332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV2894OtherBLUE CROSS OF IDAHO
ID000010014411OtherBLUE SHEILD OF IDAHO
IDV2894OtherBLUE CROSS OF IDAHO