1780933945 NPI number — SHELTON FAMILY EYE CARE, LLC

Table of content: (NPI 1780933945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780933945 NPI number — SHELTON FAMILY EYE CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELTON FAMILY EYE CARE, 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:
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:
1780933945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E WALLACE KNEELAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98584-2981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-427-8325
Provider Business Mailing Address Fax Number:
360-427-8326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E WALLACE KNEELAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98584-2981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-427-8325
Provider Business Practice Location Address Fax Number:
360-427-8326
Provider Enumeration Date:
09/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LA
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
360-601-7796

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD 60292781 , 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: 1679838874 . This is a "PERSONAL NPI" identifier . This identifiers is of the category "OTHER".




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