1043586670 NPI number — EYE INSTITUTE OF OLYMPIA INC. P.S.

Table of content: SELINA GRACE LEBOEUF LCSW (NPI 1689307068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043586670 NPI number — EYE INSTITUTE OF OLYMPIA INC. P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE INSTITUTE OF OLYMPIA INC. P.S.
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:
Provider Other Organization Name Type Code:
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:
1043586670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 LILLY RD NE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506-5428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-438-2207
Provider Business Mailing Address Fax Number:
360-438-2231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 LILLY RD NE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-5428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-438-2207
Provider Business Practice Location Address Fax Number:
360-438-2231
Provider Enumeration Date:
03/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WEEDON
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-438-2207

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD00023118 , 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)

  • Identifier: 7087539 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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