Provider Demographics
NPI:1194850925
Name:EYEJOA OPTICAL, LLC
Entity Type:Organization
Organization Name:EYEJOA OPTICAL, LLC
Other - Org Name:EYEJOA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-582-3698
Mailing Address - Street 1:8705 S TACOMA WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-4544
Mailing Address - Country:US
Mailing Address - Phone:253-582-3698
Mailing Address - Fax:
Practice Address - Street 1:8705 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4544
Practice Address - Country:US
Practice Address - Phone:253-582-3698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4020TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8705WAOtherREGENCE PROVIDER ID
WA2031326Medicaid
WA2031326Medicaid
WA2031326Medicaid
WA8856739Medicare ID - Type Unspecified