Provider Demographics
NPI:1700922044
Name:BURLEY EYE CARE CENTER, L.L.P.
Entity Type:Organization
Organization Name:BURLEY EYE CARE CENTER, L.L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DELBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:OMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-678-3539
Mailing Address - Street 1:1970 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2439
Mailing Address - Country:US
Mailing Address - Phone:208-678-3539
Mailing Address - Fax:208-678-2949
Practice Address - Street 1:1970 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2439
Practice Address - Country:US
Practice Address - Phone:208-678-3539
Practice Address - Fax:208-678-2949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-969152W00000X
IDODP-501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804162200Medicaid
ID0258810001Medicare NSC
ID1375337Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER