1265607071 NPI number — ANGELES VISION CLINIC, INC.

Table of content: (NPI 1265607071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265607071 NPI number — ANGELES VISION CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELES VISION 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:
1265607071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 GEORGIANA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ANGELES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98362-3511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-452-7661
Provider Business Mailing Address Fax Number:
360-417-0254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 GEORGIANA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ANGELES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98362-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-452-7661
Provider Business Practice Location Address Fax Number:
360-417-0254
Provider Enumeration Date:
04/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
KIRK
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-452-7661

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 1267TX , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2025484 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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