Provider Demographics
NPI:1770851446
Name:PORTER EYECARE PLLC
Entity Type:Organization
Organization Name:PORTER EYECARE PLLC
Other - Org Name:A B SEE VISION CARE PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LIN
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-757-0441
Mailing Address - Street 1:852 E PARRI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5626
Mailing Address - Country:US
Mailing Address - Phone:208-525-8686
Mailing Address - Fax:208-525-8684
Practice Address - Street 1:1480 E LINCOLN RD STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2128
Practice Address - Country:US
Practice Address - Phone:208-525-8686
Practice Address - Fax:208-525-8684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDIDP 100113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6627620001Medicare NSC