Provider Demographics
NPI:1154867125
Name:ALDERWOOD OPTOMETRIC SERVICES PLLC
Entity Type:Organization
Organization Name:ALDERWOOD OPTOMETRIC SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-771-2662
Mailing Address - Street 1:2502 196TH ST SW STE 14
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-7091
Mailing Address - Country:US
Mailing Address - Phone:425-772-2662
Mailing Address - Fax:
Practice Address - Street 1:2502 196TH ST SW STE 14
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-7091
Practice Address - Country:US
Practice Address - Phone:425-772-2662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60294865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023596Medicaid