1356413439 NPI number — FAIRHAVEN VISION CLINIC PLLC

Table of content: (NPI 1356413439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356413439 NPI number — FAIRHAVEN VISION CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRHAVEN VISION 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:
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:
1356413439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1207 OLD FAIRHAVEN PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-7411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-733-1190
Provider Business Mailing Address Fax Number:
360-734-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 OLD FAIRHAVEN PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-7411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-733-1190
Provider Business Practice Location Address Fax Number:
360-734-1306
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSEN
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
IRENE
Authorized Official Title or Position:
OPTICAL TECHNICIAN
Authorized Official Telephone Number:
360-733-1190

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD00000910 , 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: 616790001 . This is a "GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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