NPIMap

Organization Active NPI

Hayden Vision Source PLLC

Doing business as Hayden Vision Source

  • Optometrist
  • Hayden, ID
National Provider Identifier
1548999840
Registry record updated Jun 10, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
HAYDEN VISION SOURCE PLLC
Doing business as
Hayden Vision Source
Practice address
8445 N Government Way
Hayden, ID 83835-9349
Phone
(208) 772-3208
Fax
(208) 762-2574
NPI assigned
Jun 10, 2022
Last updated
Jun 10, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2022

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

Authorized official

Name
Emily Putney, CPC
Title
Credentialing Specialist
Phone
(208) 772-3208

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X NU Primary

Addresses

Primary practice location

8445 N Government Way
Hayden, ID 83835-9349

Mailing address

8445 N Government Way
Hayden, ID 83835-9349
Phone (208) 772-3208

Other identifiers 1

IdentifierTypeStateIssuer
1780345264MedicaidID

Other names 1

  • Hayden Vision Source Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220726000472 ID Part B Supplier - Clinic/Group Practice 6800282427 Receives reassigned benefits from 7 practitioners
Practice locations: Hayden, ID

National Provider Directory

National Provider Directory
Tax ID family
Hayden Vision Source2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

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.

NPI Registry JSON

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

{
    "created_epoch": "1654819200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654819200000",
    "number": "1548999840",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8445 N GOVERNMENT WAY",
            "city": "HAYDEN",
            "state": "ID",
            "postal_code": "838359349",
            "telephone_number": "208-772-3208",
            "fax_number": "208-762-2574"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8445 N GOVERNMENT WAY",
            "city": "HAYDEN",
            "state": "ID",
            "postal_code": "838359349",
            "telephone_number": "208-772-3208",
            "fax_number": "208-762-2574"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HAYDEN VISION SOURCE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-10",
        "last_updated": "2022-06-10",
        "certification_date": "2022-06-06",
        "status": "A",
        "authorized_official_last_name": "PUTNEY",
        "authorized_official_first_name": "EMILY",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "208-772-3208",
        "authorized_official_credential": "CPC"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1780345264",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hayden Vision Source",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hayden, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 2022; 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.