1396829123 NPI number — ALDERWOOD VISION CLINIC, INC. P.S.

Table of content: (NPI 1396829123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396829123 NPI number — ALDERWOOD VISION CLINIC, INC. P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALDERWOOD VISION CLINIC, INC. P.S.
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:
1396829123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18631 ALDERWOOD MALL PKWY STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98037-8057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-771-2662
Provider Business Mailing Address Fax Number:
425-670-2333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18631 ALDERWOOD MALL PKWY STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98037-8057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-771-2662
Provider Business Practice Location Address Fax Number:
425-670-2333
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HYDE
Authorized Official First Name:
IVAN
Authorized Official Middle Name:
DEREK
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-771-2662

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  600387275 , 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: 2001873 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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