Provider Demographics
NPI:1851624019
Name:LWK, P.C.
Entity Type:Organization
Organization Name:LWK, P.C.
Other - Org Name:IDAHO EYE PROS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAVAR
Authorized Official - Middle Name:W
Authorized Official - Last Name:KOFOED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-378-7020
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:208-297-7019
Mailing Address - Fax:208-297-7518
Practice Address - Street 1:291 N MILWAUKEE ST
Practice Address - Street 2:SUITE A-3
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-378-7020
Practice Address - Fax:208-375-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty