Provider Demographics
NPI:1124199435
Name:WHIDBEY VISION CARE INC PS
Entity Type:Organization
Organization Name:WHIDBEY VISION CARE INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-675-2235
Mailing Address - Street 1:PO BOX 1048
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-1048
Mailing Address - Country:US
Mailing Address - Phone:360-331-8424
Mailing Address - Fax:360-331-8425
Practice Address - Street 1:1690 MAIN ST
Practice Address - Street 2:STE 103
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249
Practice Address - Country:US
Practice Address - Phone:360-331-8424
Practice Address - Fax:360-331-8425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003150152W00000X
WAOD00003987152W00000X
WAOD00004139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006765Medicaid
WA2031367Medicaid
WAG8867700Medicare PIN
WAG8862273Medicare PIN
WA2031367Medicaid
WAGAB28331Medicare PIN
WAGAB27177Medicare PIN
WA0728290002Medicare NSC
WA2006765Medicaid