Basic Information
| Provider Information | |||||||||
| NPI: | 1669877098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S CLEAR VISION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 568 FALLS AVE | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082840650 | ||||||||
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| Address1: | 568 FALLS AVE | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082840650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2014 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | NIELSEN | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | CLARK | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 2082840650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODP-100311 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.