1770564445 NPI number — PROFESSIONAL VISION SERVICES, PS

Table of content: (NPI 1770564445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770564445 NPI number — PROFESSIONAL VISION SERVICES, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL VISION SERVICES, 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 VISION
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:
1770564445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4620 PACIFIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98408-7738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-473-3443
Provider Business Mailing Address Fax Number:
253-473-7127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4620 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98408-7738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-473-3443
Provider Business Practice Location Address Fax Number:
253-473-7127
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BIRCUMSHAW
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-473-3443

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  1349 , 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: 209-783 . This is a "OFFICE OF DISABILITY INSURANCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1203680 . This is a "DSHS VENDOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: WA0179 . This is a "NBN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 482,107-02 . This is a "L & I WORKERS COMP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 61722 . This is a "SPECTERA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: BI 0008 . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: G8878811 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: W912748 . This is a "CHAMPUS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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