NPIMap

Organization Active NPI

State of Idaho

  • Low Vision Rehabilitation Optometrist
  • Boise, ID
National Provider Identifier
1801833454
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Low Vision Rehabilitation OptometristTaxonomy code 152WL0500X
Legal business name
STATE OF IDAHO
Practice address
120 S Cole Rd
Suite 120 - BLDG 3
Boise, ID 83709-0932
Phone
(208) 334-3220
Fax
(208) 334-2963
NPI assigned
Jun 1, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Ms. Angela Roan
Title
Administrator
Phone
(208) 334-3220

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Low Vision Rehabilitation Optometrist 152WL0500X NU Primary

Addresses

Primary practice location

120 S Cole Rd
Suite 120 - BLDG 3
Boise, ID 83709-0932

Mailing address

120 S Cole Rd
Suite 120 - BLDG 3
Boise, ID 83709-0932
Phone (208) 334-3220

Other names 1

  • Idaho Commission for the Blind & Visually Impaired Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040724000290 ID Part B Supplier - Clinic/Group Practice 4789663220 Receives reassigned benefits from 1 practitioner
1 other NPI on this enrollment
Practice locations: Boise, ID

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
District 7 Health9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Practitioners & affiliated clinicians

Practitioners 9

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": "1149120000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1801833454",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 S COLE RD",
            "address_2": "SUITE 120 - BLDG 3",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837090932",
            "telephone_number": "208-334-3220",
            "fax_number": "208-334-2963"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 S COLE RD",
            "address_2": "SUITE 120 - BLDG 3",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837090932",
            "telephone_number": "208-334-3220",
            "fax_number": "208-334-2963"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF IDAHO",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "ROAN",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "208-334-3220",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "152WL0500X",
            "taxonomy_group": "",
            "desc": "Optometrist, Low Vision Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Idaho Commission for the Blind & Visually Impaired",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.