Provider Demographics
NPI:1083604946
Name:PACIFIC EYECARE OF POULSBO PS
Entity Type:Organization
Organization Name:PACIFIC EYECARE OF POULSBO PS
Other - Org Name:PACIFIC OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JC
Authorized Official - Last Name:OMOREHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-779-2020
Mailing Address - Street 1:20669 BOND RD NE
Mailing Address - Street 2:STE 100
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6525
Mailing Address - Country:US
Mailing Address - Phone:360-779-2020
Mailing Address - Fax:360-779-3093
Practice Address - Street 1:1100 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1781
Practice Address - Country:US
Practice Address - Phone:206-842-2020
Practice Address - Fax:206-780-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029555332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025633Medicaid
0376550004Medicare ID - Type Unspecified
WA2025633Medicaid