Provider Demographics
NPI:1750511184
Name:STEPHEN BROCKBANK O.D. L.L.C.
Entity Type:Organization
Organization Name:STEPHEN BROCKBANK O.D. L.L.C.
Other - Org Name:ALPINE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCKBANK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-883-1800
Mailing Address - Street 1:3510 12TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5575
Mailing Address - Country:US
Mailing Address - Phone:208-743-5830
Mailing Address - Fax:208-743-5831
Practice Address - Street 1:3510 12TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5575
Practice Address - Country:US
Practice Address - Phone:208-743-5830
Practice Address - Fax:208-743-5831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5679870001Medicare NSC