NPIMap

Organization Active NPI

St Maries Vision Center, PLLC

  • Optometrist
  • St Maries, ID
National Provider Identifier
1780190694
Registry record updated Dec 15, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
ODP1029 Issued in ID
Legal business name
ST MARIES VISION CENTER, PLLC
Practice address
704 W College Ave
St Maries, ID 83861-1824
Phone
(208) 245-6563
NPI assigned
Dec 15, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 15, 2017

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

Authorized official

Name
Dr. Lance William Fagan, ODNPI 1891775151
Title
Owner
Phone
(208) 245-6563

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
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X ODP1029 ID Primary

Addresses

Primary practice location

704 W College Ave
St Maries, ID 83861-1824

Mailing address

704 W College Ave
St Maries, ID 83861-1824
Phone (208) 245-6563

Other names 1

  • St Maries 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
O20180205001925 ID Part B Supplier - Clinic/Group Practice 6608136957 Receives reassigned benefits from 3 practitioners
Practice locations: St Maries, ID

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1513296000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1513296000000",
    "number": "1780190694",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "704 W COLLEGE AVE",
            "city": "ST MARIES",
            "state": "ID",
            "postal_code": "838611824",
            "telephone_number": "208-245-6563"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "704 W COLLEGE AVE",
            "city": "ST MARIES",
            "state": "ID",
            "postal_code": "838611824",
            "telephone_number": "208-245-6563"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST MARIES VISION CENTER, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-12-15",
        "last_updated": "2017-12-15",
        "status": "A",
        "authorized_official_last_name": "FAGAN",
        "authorized_official_first_name": "LANCE",
        "authorized_official_middle_name": "WILLIAM",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-245-6563",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "ID",
            "license": "ODP1029",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Maries Vision Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in St Maries, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2017; 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.