Provider Demographics
NPI:1164611133
Name:HOQUIAM VISION CLINIC PS
Entity Type:Organization
Organization Name:HOQUIAM VISION CLINIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-533-7395
Mailing Address - Street 1:403 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HOQUIAM
Mailing Address - State:WA
Mailing Address - Zip Code:98550-3615
Mailing Address - Country:US
Mailing Address - Phone:360-533-7395
Mailing Address - Fax:360-532-6907
Practice Address - Street 1:403 7TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-3615
Practice Address - Country:US
Practice Address - Phone:360-533-7395
Practice Address - Fax:360-532-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1404OtherSTATE LISCENSE
WA2064905Medicaid
WADD0837OtherPALMETTO - RR MEDICARE
WAT02623OtherUPIN
WA2064905Medicaid
WADD0837OtherPALMETTO - RR MEDICARE