Provider Demographics
NPI:1609982271
Name:HACKING, SALLY (OD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:HACKING
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 100024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID863683OtherDESERET MUTUAL
ID000010147629OtherBLUE SHIELD OF IDAHO
ID806951200Medicaid
IDV6507OtherBLUE CROSS OF IDAHO
ID1594322Medicare ID - Type Unspecified
ID806951200Medicaid