Provider Demographics
NPI:1972658169
Name:NORTH IDAHO EYE CLINICS, INC
Entity Type:Organization
Organization Name:NORTH IDAHO EYE CLINICS, INC
Other - Org Name:1. LAKELAND EYE CLINIC 2. KELLOGG VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-687-0370
Mailing Address - Street 1:15630 N HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8710
Mailing Address - Country:US
Mailing Address - Phone:208-687-0370
Mailing Address - Fax:208-687-0470
Practice Address - Street 1:15630 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8710
Practice Address - Country:US
Practice Address - Phone:208-687-0370
Practice Address - Fax:208-687-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6012940001Medicare NSC
1366567Medicare PIN