Provider Demographics
NPI:1275666042
Name:LAKE STEVENS VISION CLINIC, INC
Entity Type:Organization
Organization Name:LAKE STEVENS VISION CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WINDHORST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-334-4016
Mailing Address - Street 1:515 STATE ROUTE 9 NE STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-8523
Mailing Address - Country:US
Mailing Address - Phone:425-334-4016
Mailing Address - Fax:425-334-4017
Practice Address - Street 1:515 STATE ROUTE 9 NE STE 104
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-8523
Practice Address - Country:US
Practice Address - Phone:425-334-4016
Practice Address - Fax:425-334-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1315TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011146Medicaid
WA2011146Medicaid
WAG8874253Medicare PIN