Provider Demographics
NPI:1164545612
Name:CURTIS R BAXSTROM JR
Entity Type:Organization
Organization Name:CURTIS R BAXSTROM JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAXSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-661-6005
Mailing Address - Street 1:1705 S 324TH PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8504
Mailing Address - Country:US
Mailing Address - Phone:253-661-6005
Mailing Address - Fax:
Practice Address - Street 1:1705 S 324TH PL
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8504
Practice Address - Country:US
Practice Address - Phone:253-661-6005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1583152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8858862Medicare ID - Type UnspecifiedMEDICARE GROUP