Provider Demographics
NPI:1952117434
Name:RG VISION EYECARE LLC
Entity type:Organization
Organization Name:RG VISION EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-871-2936
Mailing Address - Street 1:1521 W BLUE DOWNS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8496
Mailing Address - Country:US
Mailing Address - Phone:208-871-2936
Mailing Address - Fax:208-231-8595
Practice Address - Street 1:129 W GALVANI DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8008
Practice Address - Country:US
Practice Address - Phone:208-871-2936
Practice Address - Fax:208-231-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDODP-100476OtherOD LICENSE NUMBER