1558320838 NPI number — VALLEY VISION CLINIC PS

Table of content: (NPI 1558320838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558320838 NPI number — VALLEY VISION CLINIC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY VISION CLINIC PS
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:
6
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:
1558320838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1138
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-529-2020
Provider Business Mailing Address Fax Number:
509-529-2115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-2020
Provider Business Practice Location Address Fax Number:
509-529-2115
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUNN
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
509-529-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5870377 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0067000 . This is a "DEPT OF LABOR AND INDUSTR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 610605300 . This is a "DEPT OF LABOR SEATTLE DFE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8886644808 . This is a "COMM HEALTH PLAN OF WASH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01300045 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2911402 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CO3376 . This is a "TRAVELERS MEDICARE RETIRE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001300045 . This is a "MC SUPPLY CIGNA DMERC REG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2576 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".




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