Provider Demographics
NPI:1396839197
Name:NORTHWEST OPTICAL VISION CENTER INC.
Entity Type:Organization
Organization Name:NORTHWEST OPTICAL VISION CENTER INC.
Other - Org Name:NORTHWEST OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:JACKL
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:253-572-5498
Mailing Address - Street 1:7501 BRIDGEPORT WAY W STE C
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2423
Mailing Address - Country:US
Mailing Address - Phone:253-572-5498
Mailing Address - Fax:253-409-2841
Practice Address - Street 1:7501 BRIDGEPORT WAY W STE C
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2423
Practice Address - Country:US
Practice Address - Phone:253-572-5498
Practice Address - Fax:253-409-2841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001821156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2028777Medicaid
WA5067180001Medicare ID - Type UnspecifiedCIGNA