Provider Demographics
NPI:1598876997
Name:MADISON CLINIC OPTOMETRY, P.C.
Entity Type:Organization
Organization Name:MADISON CLINIC OPTOMETRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-359-1880
Mailing Address - Street 1:244 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2022
Mailing Address - Country:US
Mailing Address - Phone:208-359-1880
Mailing Address - Fax:208-359-2025
Practice Address - Street 1:244 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2022
Practice Address - Country:US
Practice Address - Phone:208-359-1880
Practice Address - Fax:208-359-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV6499OtherBLUE CROSS
ID000010149064OtherREGENCE BLUE SHIELD OF ID
ID1377549Medicare ID - Type Unspecified