Provider Demographics
NPI:1083219752
Name:BALLARD EYE CLINIC PLLC
Entity Type:Organization
Organization Name:BALLARD EYE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
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 1:2201 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4025
Practice Address - Country:US
Practice Address - Phone:206-789-7417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty