Provider Demographics
NPI:1043756802
Name:QUEEN ANNE EYE CLINIC
Entity Type:Organization
Organization Name:QUEEN ANNE EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-282-8120
Mailing Address - Street 1:20 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-2319
Mailing Address - Country:US
Mailing Address - Phone:206-282-8120
Mailing Address - Fax:206-282-8046
Practice Address - Street 1:20 BOSTON ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2319
Practice Address - Country:US
Practice Address - Phone:206-282-8120
Practice Address - Fax:206-282-8046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD4143152W00000X
WAWA3645152W00000X
WAWA3729152W00000X
IL046010818152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty