Eagle Vision Center PC
Organization Active NPI Optometrist · Rexburg, ID
NPI 1467646265 · NPPES record last updated Nov 21, 2012
Key facts
- NPI
- 1467646265
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- ODP100035 (ID)
- Legal business name
- EAGLE VISION CENTER PC
- Practice address
- 74 E 1St S
Rexburg, ID 83440-1936 - Phone
- (208) 356-6911
- Fax
- (208) 356-3185
- NPI assigned
- Sep 5, 2007
- Organization subpart
- No
Authorized official
- Name
- Shawn Taylor Galbraith, OD
- Title
- Doctor
- Phone
- (208) 356-6911
Practitioners 3
-
Natalie Nelson, O.D.
-
Mitch Clay Merrill, O.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WY
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071112000185 | WY | Part B Supplier - Clinic/Group Practice | 1951496579 |
Receives reassigned benefits from 2 practitioners Practice locations: Jackson, WY |
National Provider Directory
Locations
74 E 1st S
Rexburg, ID 83440
Phone (208) 356-6911
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | ODP100035 | ID | Yes |
Addresses
Primary practice location
74 E 1St S
Rexburg, ID 83440-1936
Mailing address
74 E 1St S
Rexburg, ID 83440-1936
Phone (208) 356-6911
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 807725600 | Medicaid | ID |
Other providers in Rexburg, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 21, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.