Provider Demographics
NPI:1356542542
Name:VISION QUEST MEDICAL CENTER, PA
Entity type:Organization
Organization Name:VISION QUEST MEDICAL CENTER, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-377-3937
Mailing Address - Street 1:5680 W GAGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1326
Mailing Address - Country:US
Mailing Address - Phone:208-377-3937
Mailing Address - Fax:208-377-9455
Practice Address - Street 1:5680 W GAGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1326
Practice Address - Country:US
Practice Address - Phone:208-377-3937
Practice Address - Fax:208-377-9455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100002152W00000X
IDODP-100417152W00000X
IDO-0860207W00000X
IDM4623207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000160500Medicaid
ID807072200Medicaid
ID807072300Medicaid
ID0857720001OtherDMERC GROUP NO
ID806834700Medicaid
ID001553800Medicaid
ID000160500Medicaid
T44319Medicare UPIN
ID807072300Medicaid
ID1375000Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
1115823Medicare PIN
ID806834700Medicaid
IDCD8014Medicare PIN
ID0857720001OtherDMERC GROUP NO