Provider Demographics
NPI:1336251073
Name:TREASURE VALLEY EYE CENTER P A
Entity Type:Organization
Organization Name:TREASURE VALLEY EYE CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-706-2020
Mailing Address - Street 1:3045 E ST LUKES ST # 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3507
Mailing Address - Country:US
Mailing Address - Phone:208-288-2020
Mailing Address - Fax:208-288-2015
Practice Address - Street 1:3045 E ST LUKES ST # 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3507
Practice Address - Country:US
Practice Address - Phone:208-288-2020
Practice Address - Fax:208-288-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7853207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5854480001Medicare NSC