Provider Demographics
NPI:1013254549
Name:PARKWAY EYECARE, P.C.
Entity type:Organization
Organization Name:PARKWAY EYECARE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-357-5733
Mailing Address - Street 1:320 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4329
Mailing Address - Country:US
Mailing Address - Phone:208-524-4552
Mailing Address - Fax:208-524-4559
Practice Address - Street 1:320 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4329
Practice Address - Country:US
Practice Address - Phone:208-524-4552
Practice Address - Fax:208-524-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100034152W00000X
IDODP-638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806877400Medicaid
ID806877400Medicaid