Provider Demographics
NPI:1841332343
Name:LITTLE MO'S OPTICAL BOUTIQUE
Entity type:Organization
Organization Name:LITTLE MO'S OPTICAL BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:208-664-4011
Mailing Address - Street 1:1720 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:COEURD ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-664-4011
Mailing Address - Fax:208-664-4022
Practice Address - Street 1:1720 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEURD ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-664-4011
Practice Address - Fax:208-664-4022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332H00000X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1025900001Medicare ID - Type Unspecified