Provider Demographics
NPI:1992198675
Name:VISTEC LLC
Entity Type:Organization
Organization Name:VISTEC LLC
Other - Org Name:WALLACE L CHRISTENSENSEN, OD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-237-7666
Mailing Address - Street 1:1246 YELLOWSTONE AVE STE A4
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4372
Mailing Address - Country:US
Mailing Address - Phone:208-237-7666
Mailing Address - Fax:208-237-7400
Practice Address - Street 1:1246 YELLOWSTONE AVE STE A4
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4372
Practice Address - Country:US
Practice Address - Phone:208-237-7666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-0721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002875500Medicaid