Provider Demographics
NPI:1124224217
Name:MAPLE VALLEY EYE CARE CENTER PS
Entity Type:Organization
Organization Name:MAPLE VALLEY EYE CARE CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KEIL
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-413-8787
Mailing Address - Street 1:27010 B MAPLE VALLEY HWY SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038
Mailing Address - Country:US
Mailing Address - Phone:425-413-8787
Mailing Address - Fax:
Practice Address - Street 1:27010 B MAPLE VALLEY HWY SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-413-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3489TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1376632539OtherINDIVIDUAL NPI FOR R NEAL
WA2022853Medicaid
WA8802060Medicare PIN
WA2022853Medicaid