Provider Demographics
NPI:1407007016
Name:KETTLE FALLS VISION CLINIC
Entity Type:Organization
Organization Name:KETTLE FALLS VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:REEVE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-738-2191
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-0475
Mailing Address - Country:US
Mailing Address - Phone:509-738-2191
Mailing Address - Fax:509-738-4840
Practice Address - Street 1:W 355 3RD AVENUE
Practice Address - Street 2:UNIT 2
Practice Address - City:KETTLE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99141-9551
Practice Address - Country:US
Practice Address - Phone:509-738-2191
Practice Address - Fax:509-738-4840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001893152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0990280001Medicare NSC