1962783829 NPI number — PROVISION EYE CLINIC, INC.

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 1962783829 NPI number — PROVISION EYE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVISION EYE CLINIC, INC.
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:
1962783829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26229 125TH PL SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98030-7976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-933-0078
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17432 SE 270TH PL
Provider Second Line Business Practice Location Address:
INSIDE WALMART VISION CENTER
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98042-4962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-630-8718
Provider Business Practice Location Address Fax Number:
253-630-8720
Provider Enumeration Date:
09/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LEUNG
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-933-0078

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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