Provider Demographics
NPI:1942770169
Name:IDAHO PHYSICIANS EYECARE GROUP, P.C.
Entity Type:Organization
Organization Name:IDAHO PHYSICIANS EYECARE GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-208-8464
Mailing Address - Street 1:3801 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4140
Mailing Address - Country:US
Mailing Address - Phone:561-275-2020
Mailing Address - Fax:
Practice Address - Street 1:1700 W KARCHER RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1531
Practice Address - Country:US
Practice Address - Phone:208-606-0374
Practice Address - Fax:208-318-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty