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Organization

EYE CLINIC OF SANDPOINT PA

Active
Organization subpart
No

Provider details

NPI number
Authorized official
DR. JASON M PETERSEN DO (PHYSICIAN-OWNER)
(208) 263-8501
Entity
Organization

Contact information

Practice address
307 S 1ST AVE, SANDPOINT, ID 83864-1201
(208) 263-8501
Mailing address
307 S 1ST AVE, SANDPOINT, ID 83864-1201
(208) 263-8501

Taxonomy

Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
0377150001
NORIDIAN DMERC SUPPLIER
ID
Enumeration date
03/08/2007
Last updated
02/15/2018
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