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Organization
TOTAL VISION PA
Active
Organization
TOTAL VISION PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SHEREE C SHANNON (ADMINISTRATIVE ASSISTANT)
(208) 459-2641
Entity
Organization
Contact information
Practice address
1702 S KIMBALL AVE, CALDWELL, ID 83605-4826
(208) 459-2641
(208) 459-2895
Mailing address
1702 S KIMBALL AVE, CALDWELL, ID 83605-4826
(208) 459-2641
(208) 459-2895
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
ODP-579
ID
152W00000X
Optometrist
ODP100163
ID
152WC0802X
Corneal and Contact Management Optometrist
Primary
ODP-579
ID
152WC0802X
Corneal and Contact Management Optometrist
ODP100163
ID
152WL0500X
Low Vision Rehabilitation Optometrist
ODP100163
ID
152WP0200X
Pediatric Optometrist
ODP-579
ID
152WP0200X
Pediatric Optometrist
ODP100163
ID
152WS0006X
Sports Vision Optometrist
ODP100163
ID
152WX0102X
Occupational Vision Optometrist
ODP100163
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807869000
—
ID
01
—
V9055
BLUE CROSS OF IDAHO GROUP
ID
Enumeration date
11/30/2006
Last updated
06/28/2010
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