NPIMap

Organization Active NPI

Kootenai Vision, PLLC

Doing business as Kootenai Vision Center

  • Optometrist
  • Coeur d'Alene, ID
National Provider Identifier
1386856284
Registry record updated Apr 12, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
ODP1029 Issued in ID
Legal business name
KOOTENAI VISION, PLLC
Doing business as
Kootenai Vision Center
Practice address
1801 N Third St
Coeur D Alene, ID 83814
Phone
(208) 667-1591
Fax
(208) 676-8574
NPI assigned
May 4, 2007
Last updated
Apr 12, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 12, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Lance William Fagan, O.D.NPI 1891775151
Title
Managing Member
Phone
(208) 667-2591

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X ODP1029 ID Primary

Addresses

Primary practice location

1801 N Third St
Coeur D Alene, ID 83814

Mailing address

1801 N Third St
Coeur D Alene, ID 83814
Phone (208) 667-1591

Other names 1

  • Kootenai Vision Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050422000646 ID Part B Supplier - Clinic/Group Practice 4284672890 Receives reassigned benefits from 3 practitioners
Practice locations: Coeur D Alene, ID; Post Falls, ID

National Provider Directory

National Provider Directory

Locations

1801 N 3rd St
Coeur D Alene, ID 83814
Phone (208) 667-1591

1101 E Polston Ave
Post Falls, ID 83854
Phone (208) 699-6817

Practitioners & affiliated clinicians

Practitioners 3

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.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178236800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1302566400000",
    "number": "1386856284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1801 N THIRD ST",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "83814",
            "telephone_number": "208-667-1591",
            "fax_number": "208-676-8574"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1801 N THIRD ST",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "83814",
            "telephone_number": "208-667-1591",
            "fax_number": "208-676-8574"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KOOTENAI VISION, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-04",
        "last_updated": "2011-04-12",
        "status": "A",
        "authorized_official_last_name": "FAGAN",
        "authorized_official_first_name": "LANCE",
        "authorized_official_middle_name": "WILLIAM",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "208-667-2591",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "ID",
            "license": "ODP1029",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kootenai Vision Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Coeur d'Alene, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2011; 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.

Verify at the official NPI Registry.