Provider Demographics
NPI:1326236100
Name:FAMILY VISION CENTER OF TACOMA
Entity Type:Organization
Organization Name:FAMILY VISION CENTER OF TACOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:WENDELL
Authorized Official - Last Name:GORHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-759-5679
Mailing Address - Street 1:6411 87TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6214
Mailing Address - Country:US
Mailing Address - Phone:253-686-2770
Mailing Address - Fax:253-759-0785
Practice Address - Street 1:2514 N. ADAMS ST.
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406
Practice Address - Country:US
Practice Address - Phone:253-759-5679
Practice Address - Fax:253-759-0785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3056TX152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2718302Medicaid
WAT02777Medicare UPIN
WAU85644Medicare UPIN
WA2718302Medicaid