Provider Demographics
NPI:1326111501
Name:PORT ORCHARD EYECARE CENTERS INC, PS
Entity Type:Organization
Organization Name:PORT ORCHARD EYECARE CENTERS INC, PS
Other - Org Name:20/20 EYECARE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-874-2020
Mailing Address - Street 1:1703 SEDGWICK RD
Mailing Address - Street 2:STE 111
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-9599
Mailing Address - Country:US
Mailing Address - Phone:360-874-2020
Mailing Address - Fax:360-874-0567
Practice Address - Street 1:1703 SEDGWICK RD
Practice Address - Street 2:STE 111
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-9599
Practice Address - Country:US
Practice Address - Phone:360-874-2020
Practice Address - Fax:360-874-0567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8803643Medicare PIN
WA5128050001Medicare NSC