Provider Demographics
NPI:1861485989
Name:DANIEL L TILLER PA
Entity Type:Organization
Organization Name:DANIEL L TILLER PA
Other - Org Name:ADVANCED EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-466-9251
Mailing Address - Street 1:901 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4658
Mailing Address - Country:US
Mailing Address - Phone:208-466-9251
Mailing Address - Fax:208-463-1714
Practice Address - Street 1:901 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4658
Practice Address - Country:US
Practice Address - Phone:208-466-9251
Practice Address - Fax:208-463-1714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807007400Medicaid
IDV213-4OtherBLUE CROSS OF IDAHO
IDV213-4OtherBLUE CROSS OF IDAHO
ID1375555Medicare PIN