Provider Demographics
NPI:1235517541
Name:BRIDGEPORT FAMILY VISION CLINIC, PLLC
Entity Type:Organization
Organization Name:BRIDGEPORT FAMILY VISION CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TOSLAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-357-6683
Mailing Address - Street 1:9101 BRIDGEPORT WAY SW
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2419
Mailing Address - Country:US
Mailing Address - Phone:253-588-2254
Mailing Address - Fax:253-588-0545
Practice Address - Street 1:9101 BRIDGEPORT WAY SW
Practice Address - Street 2:SUITE C
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2419
Practice Address - Country:US
Practice Address - Phone:253-588-2254
Practice Address - Fax:253-588-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD1574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty