Provider Demographics
NPI:1356496871
Name:AHRENS, RICHARD (LDO)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:AHRENS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1505
Mailing Address - Country:US
Mailing Address - Phone:360-794-5941
Mailing Address - Fax:360-200-5278
Practice Address - Street 1:121 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1505
Practice Address - Country:US
Practice Address - Phone:360-794-5941
Practice Address - Fax:360-200-5278
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00000565156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030583Medicaid
WA2030583Medicaid