Provider Demographics
NPI:1093912933
Name:MOUNT VERNON VISION SOURCE PS INC
Entity Type:Organization
Organization Name:MOUNT VERNON VISION SOURCE PS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOD
Authorized Official - Middle Name:W
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-424-4181
Mailing Address - Street 1:1616 N 18TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2600
Mailing Address - Country:US
Mailing Address - Phone:360-424-4181
Mailing Address - Fax:360-424-6414
Practice Address - Street 1:1616 N 18TH ST STE 104
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2600
Practice Address - Country:US
Practice Address - Phone:360-424-4181
Practice Address - Fax:360-424-6414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024057Medicaid
WA410044967OtherRR MEDICARE
WAU77387Medicare UPIN
WAG8942163Medicare PIN
WA3945970001Medicare NSC