| NPI | 1104957612 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JASON M PETERSEN Physician Owner 208-263-8501 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332H00000X Eyewear Supplier (Equipment, not the service) |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2018-02-15 |