Provider Demographics
NPI:1780784769
Name:PARKWAY EYECARE PC
Entity type:Organization
Organization Name:PARKWAY EYECARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-357-5733
Mailing Address - Street 1:524 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1154
Mailing Address - Country:US
Mailing Address - Phone:208-357-5733
Mailing Address - Fax:208-357-2240
Practice Address - Street 1:524 N STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1154
Practice Address - Country:US
Practice Address - Phone:208-357-5733
Practice Address - Fax:208-357-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 100034152W00000X
IDODP 638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806877400Medicaid
ID806877400Medicaid