1841558848 NPI number — COMMUNITY EYECARE CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841558848 NPI number — COMMUNITY EYECARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY EYECARE CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EYEWEAR GALLERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841558848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
728 S 320TH ST STE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-5255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-941-3937
Provider Business Mailing Address Fax Number:
253-941-3935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
728 S 320TH ST STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-5255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-941-3937
Provider Business Practice Location Address Fax Number:
253-941-3935
Provider Enumeration Date:
04/26/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOMAN
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-941-3937

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  OD 00004137 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)