1972559458 NPI number — CENTRAL WASHINGTON EYE CLINIC PLLC

Table of content: (NPI 1972559458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972559458 NPI number — CENTRAL WASHINGTON EYE CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL WASHINGTON EYE CLINIC PLLC
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:
WASHINGTON VALLEY EYE & LASER CENTER
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:
1972559458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/03/2021
NPI Reactivation Date:
03/25/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3902 CREEKSIDE LOOP
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-4876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-452-6611
Provider Business Mailing Address Fax Number:
509-248-0621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 SW 41ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98057-4926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-255-4250
Provider Business Practice Location Address Fax Number:
425-271-3294
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LI
Authorized Official First Name:
ABEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-255-4250

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD00038596 , 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: CE3333 . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7114580 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135530 . This is a "LABOR AND INDUSTRIES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180045644 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8933290 . This is a "CRIME VICTIMS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com