1811986870 NPI number — PACIFIC EYE CARE OF POULSBO 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 1811986870 NPI number — PACIFIC EYE CARE OF POULSBO PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC EYE CARE OF POULSBO 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:
1811986870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
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:
360-779-3093
Provider Business Mailing Address Fax Number:
360-779-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 BETHEL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-3125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-895-2020
Provider Business Practice Location Address Fax Number:
360-874-0048
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OMORCHOE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JC
Authorized Official Title or Position:
MD/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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