Individual
DR. JILL MARIE LANE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
405 E MAIN ST, GRANGEVILLE, ID 83530-2239
(208) 983-3732
(208) 983-3738
Mailing address
217 SE 10TH ST, GRANGEVILLE, ID 83530-5127
(208) 983-3494
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
ODP-100095
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2031383
—
WA
05
—
807324600
—
ID
01
—
V7168
BLUE CROSS OF IDAHO
ID
Enumeration date
12/13/2006
Last updated
01/12/2017
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