1659435709 NPI number — PACIFIC NORTHWEST EYE CARE, PS

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 1659435709 NPI number — PACIFIC NORTHWEST EYE CARE, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC NORTHWEST EYE CARE, 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:
Provider Other Organization Name Type Code:
6
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:
1659435709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 BLACK LAKE BLVD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98512-5651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-570-1780
Provider Business Mailing Address Fax Number:
360-570-1801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 BLACK LAKE BLVD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98512-5651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-570-1780
Provider Business Practice Location Address Fax Number:
360-570-1801
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
BEN
Authorized Official Middle Name:
HAROLD
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
360-570-1780

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 2025112 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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