Provider Demographics
NPI:1043718257
Name:ENUMCLAW VISION CLINIC PLLC
Entity Type:Organization
Organization Name:ENUMCLAW VISION CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEABURG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-825-1614
Mailing Address - Street 1:2823 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2322
Mailing Address - Country:US
Mailing Address - Phone:360-825-1614
Mailing Address - Fax:360-825-8034
Practice Address - Street 1:2823 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2322
Practice Address - Country:US
Practice Address - Phone:360-825-1614
Practice Address - Fax:360-825-8034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty