Provider Demographics
NPI:1265589048
Name:EYECARE ASSOCIATES OF EASTGATE PA
Entity type:Organization
Organization Name:EYECARE ASSOCIATES OF EASTGATE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINBIGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-344-8758
Mailing Address - Street 1:939 W. BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5118
Mailing Address - Country:US
Mailing Address - Phone:208-344-8758
Mailing Address - Fax:208-331-3379
Practice Address - Street 1:939 W. BEACON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5118
Practice Address - Country:US
Practice Address - Phone:208-344-8758
Practice Address - Fax:208-331-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-718332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002622500Medicaid
IDV6622OtherBLUE CROSS
ID000010015349OtherBLUE SHIELD
ID1243380001Medicare NSC
IDV6622OtherBLUE CROSS
ID159-1510Medicare ID - Type Unspecified