Provider Demographics
NPI:1407941701
Name:SPYGLASS OPTIK, P.S.
Entity Type:Organization
Organization Name:SPYGLASS OPTIK, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-671-7107
Mailing Address - Street 1:11 BELLWETHER WAY
Mailing Address - Street 2:STE 104
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2957
Mailing Address - Country:US
Mailing Address - Phone:360-671-7107
Mailing Address - Fax:360-312-5471
Practice Address - Street 1:11 BELLWETHER WAY
Practice Address - Street 2:STE 104
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2957
Practice Address - Country:US
Practice Address - Phone:360-671-7107
Practice Address - Fax:360-312-5471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031631Medicaid
WAG8854344Medicare PIN
WA2031631Medicaid
WA6229160001Medicare NSC