Provider Demographics
NPI:1447540802
Name:COLE FAMILY EYE CENTER, PA
Entity type:Organization
Organization Name:COLE FAMILY EYE CENTER, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GALVAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-377-1102
Mailing Address - Street 1:8102 W NORTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4406
Mailing Address - Country:US
Mailing Address - Phone:208-377-1102
Mailing Address - Fax:208-377-5853
Practice Address - Street 1:8102 W NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-377-1102
Practice Address - Fax:208-377-5853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100177152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1594528Medicare PIN