Provider Demographics
NPI:1598881351
Name:COEUR DALENE VISION SOURCE
Entity Type:Organization
Organization Name:COEUR DALENE VISION SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-765-2020
Mailing Address - Street 1:3879 N SCHREIBER WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8362
Mailing Address - Country:US
Mailing Address - Phone:208-765-2020
Mailing Address - Fax:208-765-1460
Practice Address - Street 1:3879 N SCHREIBER WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8362
Practice Address - Country:US
Practice Address - Phone:208-765-2020
Practice Address - Fax:208-765-1460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807085000Medicaid
ID0685920001Medicare NSC
ID1378789Medicare PIN