Provider Demographics
NPI:1134284151
Name:HOLLENBECK, GRADY G (OD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:G
Last Name:HOLLENBECK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17224 SE 272ND ST
Mailing Address - Street 2:STE B
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4953
Mailing Address - Country:US
Mailing Address - Phone:425-260-6428
Mailing Address - Fax:
Practice Address - Street 1:17224 SE 272ND ST
Practice Address - Street 2:STE B
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4953
Practice Address - Country:US
Practice Address - Phone:425-260-6428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3816152W00000X
HI710152W00000X
MN3223152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U98206Medicare UPIN