Active NPI
Eyecenter PA
Doing business as Ketchum Eyecenter
- Optometrist
- Ketchum, ID
National Provider Identifier
1174632244
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- Legal business name
- EYECENTER PA
- Doing business as
- Ketchum Eyecenter
- Practice address
- 180 1St Ave N
Ketchum, ID 83340-6129 - Phone
- (208) 726-3363
- Fax
- (208) 726-0138
- NPI assigned
- Aug 30, 2006
- Organization subpart
- Yes
- Parent organization
- EYECENTER PA
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Robert B Grill, OD
- Title
- Owner Optometrist
- Phone
- (208) 734-9800
Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | Primary |
Addresses
Primary practice location
180 1St Ave N
Ketchum, ID 83340-6129
Mailing address
PO Box 6129
Ketchum, ID 83340-6129
Phone (208) 726-3363
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| CP7637 | Other | TRAVELERS RR MEDICARE GRP |
Other names 1
- Ketchum Eyecenter
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20051107001076 | ID | Part B Supplier - Clinic/Group Practice | 4486672565 |
Receives reassigned benefits from 5 practitioners 3 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Ketchum, ID; Twin Falls, ID; Jerome, ID; Hailey, ID |
Other NPIs on the same Medicare enrollment 3
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider Directory- Part of
- Hailey Eyecenter
Locations
201 S Lincoln Ave
Jerome, ID 83338
Phone (208) 324-4363
Practitioners & affiliated clinicians
Practitioners 7
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.
-
- Optometrist
- Twin Falls, ID
- NPI 1639280951
-
- Optometrist
- Jerome, ID
- NPI 1164533485
-
- Optometrist
- Twin Falls, ID
- NPI 1023498037
-
- Optometrist
- Twin Falls, ID
- NPI 1750996740
-
- Optometrist
- Hailey, ID
- NPI 1770694093
-
- Optometrist
- Ketchum, ID
- NPI 1649381955
-
- Optometrist
- Chicago, IL
- NPI 1720095532
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156896000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1199750400000",
"number": "1174632244",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 6129",
"city": "KETCHUM",
"state": "ID",
"postal_code": "833406129",
"telephone_number": "208-726-3363",
"fax_number": "208-726-0138"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "180 1ST AVE N",
"city": "KETCHUM",
"state": "ID",
"postal_code": "833406129",
"telephone_number": "208-726-3363",
"fax_number": "208-726-0138"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "EYECENTER PA",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "EYECENTER PA",
"enumeration_date": "2006-08-30",
"last_updated": "2008-01-08",
"status": "A",
"authorized_official_last_name": "GRILL",
"authorized_official_first_name": "ROBERT",
"authorized_official_middle_name": "B",
"authorized_official_title_or_position": "OWNER OPTOMETRIST",
"authorized_official_telephone_number": "208-734-9800",
"authorized_official_credential": "OD"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Optometrist",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRAVELERS RR MEDICARE GRP",
"identifier": "CP7637",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Ketchum Eyecenter",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Ketchum, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.