Provider Demographics
NPI:1801830666
Name:REXBURG VISION CENTER
Entity Type:Organization
Organization Name:REXBURG VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HATCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-356-4444
Mailing Address - Street 1:49 E 1ST S
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1966
Mailing Address - Country:US
Mailing Address - Phone:208-356-4444
Mailing Address - Fax:208-356-4445
Practice Address - Street 1:49 E 1ST S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1966
Practice Address - Country:US
Practice Address - Phone:208-356-4444
Practice Address - Fax:208-356-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
IDODP-100403332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0645750001Medicare NSC
ID1593337Medicare PIN