1386992717 NPI number — SPOKANE OPTICAL COMPANY LLC

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 1386992717 NPI number — SPOKANE OPTICAL COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPOKANE OPTICAL COMPANY LLC
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:
SPOKANE OPTICAL COMPANY LLC
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:
1386992717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
427 S BERNARD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-456-0107
Provider Business Mailing Address Fax Number:
509-747-2635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9651 N NEVADA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-489-1272
Provider Business Practice Location Address Fax Number:
509-489-8756
Provider Enumeration Date:
08/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSON
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
509-456-0107

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  602617024 , 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)





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