1174724215 NPI number — EYE INSTITUTE, PC

Table of content: (NPI 1174724215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174724215 NPI number — EYE INSTITUTE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE INSTITUTE, PC
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:
1174724215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 4TH AVE NW
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98027-9371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-606-1359
Provider Business Mailing Address Fax Number:
425-642-8290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 4TH AVE NW
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-9371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-606-1359
Provider Business Practice Location Address Fax Number:
425-642-8290
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDOVAL
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
VAUGHN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-606-1359

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD00048106 , 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: A20739210 . This is a "BCBS NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 806458 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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