Provider Demographics
NPI:1376730382
Name:PEARL EYE CARE CENTER, P.S.
Entity Type:Organization
Organization Name:PEARL EYE CARE CENTER, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-472-1188
Mailing Address - Street 1:2505 S 38TH ST STE A108
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7372
Mailing Address - Country:US
Mailing Address - Phone:253-472-1188
Mailing Address - Fax:253-472-3594
Practice Address - Street 1:5016 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-2039
Practice Address - Country:US
Practice Address - Phone:253-472-1188
Practice Address - Fax:253-472-3594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1426TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2003416Medicaid
GAB 16985Medicare PIN