Provider Demographics
NPI:1649601006
Name:CARMINE PETRACCA
Entity Type:Organization
Organization Name:CARMINE PETRACCA
Other - Org Name:BRYDEN FAMILY VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRACCA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-743-1761
Mailing Address - Street 1:939 BRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5057
Mailing Address - Country:US
Mailing Address - Phone:208-743-1761
Mailing Address - Fax:208-746-8042
Practice Address - Street 1:939 BRYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5057
Practice Address - Country:US
Practice Address - Phone:208-743-1761
Practice Address - Fax:208-746-8042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-634261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service