Provider Demographics
NPI:1093830648
Name:EYE CLINIC OF BELLEVUE LTD PS
Entity Type:Organization
Organization Name:EYE CLINIC OF BELLEVUE LTD PS
Other - Org Name:OVERLAKE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLZIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-454-3133
Mailing Address - Street 1:1300 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3808
Mailing Address - Country:US
Mailing Address - Phone:425-454-7989
Mailing Address - Fax:425-454-7915
Practice Address - Street 1:1300 116TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3808
Practice Address - Country:US
Practice Address - Phone:425-454-7989
Practice Address - Fax:425-454-7915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA07392332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0195900001Medicare NSC