Provider Demographics
NPI:1346574290
Name:SPANAWAY EYECARE, P.S.
Entity Type:Organization
Organization Name:SPANAWAY EYECARE, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-324-8764
Mailing Address - Street 1:1314 182ND STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-1917
Mailing Address - Country:US
Mailing Address - Phone:253-324-8764
Mailing Address - Fax:253-964-1696
Practice Address - Street 1:20307 MOUNTAIN HWY E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8101
Practice Address - Country:US
Practice Address - Phone:253-324-8764
Practice Address - Fax:253-846-7986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWA0928OtherNBN
WA19068OtherSPECTERA
WA49034OtherDAVIS
WA49034OtherDAVIS