Provider Demographics
NPI:1902810757
Name:MOUNTAIN WEST OPTICAL INC
Entity Type:Organization
Organization Name:MOUNTAIN WEST OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRANMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-3937
Mailing Address - Street 1:731 N COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-734-3937
Mailing Address - Fax:208-734-7585
Practice Address - Street 1:731 N COLLEGE RD
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-734-3937
Practice Address - Fax:208-734-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0639230001Medicare UPIN
ID1376256Medicare ID - Type Unspecified