Provider Demographics
NPI:1134204100
Name:EYECARE ASSOCIATES OF NAMPA PA
Entity type:Organization
Organization Name:EYECARE ASSOCIATES OF NAMPA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCGOURTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-467-1361
Mailing Address - Street 1:310 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3765
Mailing Address - Country:US
Mailing Address - Phone:208-467-1361
Mailing Address - Fax:208-467-9008
Practice Address - Street 1:310 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3765
Practice Address - Country:US
Practice Address - Phone:208-467-1361
Practice Address - Fax:208-467-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002622300Medicaid
ID000010015424OtherREGENCE BLUE SHIELD
IDV9063OtherBLUE CROSS
ID000010015424OtherREGENCE BLUE SHIELD
ID=========83651A001OtherTRICARE
IDE00=========OtherAETNA