1871683144 NPI number — RENTON VISION CENTER INC PS

Table of content: (NPI 1871683144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871683144 NPI number — RENTON VISION CENTER INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENTON VISION CENTER INC 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:
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:
1871683144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23896
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98093-0896
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-735-6163
Provider Business Mailing Address Fax Number:
253-840-5543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13909 MERIDIAN E
Provider Second Line Business Practice Location Address:
A3
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98373-9180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-1575
Provider Business Practice Location Address Fax Number:
253-840-5543
Provider Enumeration Date:
10/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-841-1575

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1004TX , 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: 2007664 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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