Provider Demographics
NPI:1487764981
Name:VIVA ENTERPRISES
Entity type:Organization
Organization Name:VIVA ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-265-4140
Mailing Address - Street 1:1333 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:208-265-4140
Mailing Address - Fax:208-265-4448
Practice Address - Street 1:1333 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-265-4140
Practice Address - Fax:208-265-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP602152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T76545Medicare UPIN
1371637Medicare ID - Type Unspecified