Provider Demographics
NPI:1174641690
Name:CREVISTON AND PEDERSEN LLC
Entity Type:Organization
Organization Name:CREVISTON AND PEDERSEN LLC
Other - Org Name:VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-765-2125
Mailing Address - Street 1:601 S PIONEER WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4801
Mailing Address - Country:US
Mailing Address - Phone:509-765-2125
Mailing Address - Fax:509-766-0147
Practice Address - Street 1:601 S PIONEER WAY
Practice Address - Street 2:SUITE D
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4801
Practice Address - Country:US
Practice Address - Phone:509-765-2125
Practice Address - Fax:509-766-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001428Medicaid
WA2001428Medicaid
WAG8850190Medicare PIN