Provider Demographics
NPI:1346319878
Name:NORTHWEST OPTOMETRY LLC
Entity Type:Organization
Organization Name:NORTHWEST OPTOMETRY LLC
Other - Org Name:JUNEAU EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-800-8108
Mailing Address - Street 1:1784 N 1450 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5761
Mailing Address - Country:US
Mailing Address - Phone:801-800-8108
Mailing Address - Fax:
Practice Address - Street 1:5225 COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7210
Practice Address - Country:US
Practice Address - Phone:907-318-1418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8858952Medicare ID - Type Unspecified