1386633345 NPI number — PACIFIC EYECARE OF PAULSBO PS

Table of content: (NPI 1386633345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386633345 NPI number — PACIFIC EYECARE OF PAULSBO PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC EYECARE OF PAULSBO PS
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:
PACIFIC OPTICAL
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:
1386633345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20669 BOND RD NE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
POULSBO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98370-6525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-779-2020
Provider Business Mailing Address Fax Number:
360-779-3093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10049 KITSAP MALL BLVD NW
Provider Second Line Business Practice Location Address:
STE 109
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-698-3937
Provider Business Practice Location Address Fax Number:
360-698-9882
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OMOVCHOC
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JC
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-779-2020

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  MD00029555 , 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: 2025633 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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