Provider Demographics
NPI:1801833454
Name:STATE OF IDAHO
Entity Type:Organization
Organization Name:STATE OF IDAHO
Other - Org Name:IDAHO COMMISSION FOR THE BLIND & VISUALLY IMPAIRED
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-334-3220
Mailing Address - Street 1:120 S COLE RD
Mailing Address - Street 2:SUITE 120 - BLDG 3
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0932
Mailing Address - Country:US
Mailing Address - Phone:208-334-3220
Mailing Address - Fax:208-334-2963
Practice Address - Street 1:120 S COLE RD
Practice Address - Street 2:SUITE 120 - BLDG 3
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0932
Practice Address - Country:US
Practice Address - Phone:208-334-3220
Practice Address - Fax:208-334-2963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty