Provider Demographics
NPI:1699845503
Name:EAGLE VISION ONE PLLC
Entity Type:Organization
Organization Name:EAGLE VISION ONE PLLC
Other - Org Name:VISION ONE EAGLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-938-2015
Mailing Address - Street 1:355 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5912
Mailing Address - Country:US
Mailing Address - Phone:208-939-2773
Mailing Address - Fax:208-939-5755
Practice Address - Street 1:355 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5912
Practice Address - Country:US
Practice Address - Phone:208-939-2773
Practice Address - Fax:208-939-5755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010135320OtherBLUE SHIELD
IDV4916OtherBLUE CROSS
ID5675480001OtherMEDICARE DMERC
ID806190300Medicaid
ID806190300Medicaid