Provider Demographics
NPI:1376556514
Name:EYE CARE SPECIALISTS PS
Entity Type:Organization
Organization Name:EYE CARE SPECIALISTS PS
Other - Org Name:THE LASER AND SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-758-8811
Mailing Address - Street 1:500 PORT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1835
Mailing Address - Country:US
Mailing Address - Phone:509-758-8811
Mailing Address - Fax:509-751-1188
Practice Address - Street 1:500 PORT DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1835
Practice Address - Country:US
Practice Address - Phone:509-758-8811
Practice Address - Fax:509-751-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00014109207W00000X
WA601269693261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000776OtherREGENCE BLUE SHIELD OF IDAHO
WA7088982Medicaid
000010000776OtherFEDERAL BLUE CROSS
IDOA263OtherBLUE CROSS OF IDAHO
WA8929432OtherCRIME VICTIMS COMPENSATION ACT
WA0159901OtherLABOR & INDUSTRY
ID805245400Medicaid
WA7088982Medicaid
IDOA263OtherBLUE CROSS OF IDAHO
WA7088982Medicaid