Provider Demographics
NPI:1114190790
Name:PACIFIC OPTICAL INC
Entity Type:Organization
Organization Name:PACIFIC OPTICAL INC
Other - Org Name:PACIFIC OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:D
Authorized Official - Last Name:FUJISAKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-253-3972
Mailing Address - Street 1:16420 SE MCGUILLIVRAY BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:960-253-3972
Mailing Address - Fax:360-253-5476
Practice Address - Street 1:16420 SE MCGILLIVRAY BLVD
Practice Address - Street 2:STE 105
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3461
Practice Address - Country:US
Practice Address - Phone:360-253-3972
Practice Address - Fax:360-253-5476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3169T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1152320001Medicare NSC