Provider Demographics
NPI:1417123472
Name:AHRENS VALLEY EYEWORKS
Entity Type:Organization
Organization Name:AHRENS VALLEY EYEWORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:AHRENS
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:360-794-5941
Mailing Address - Street 1:121 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1505
Mailing Address - Country:US
Mailing Address - Phone:360-794-5941
Mailing Address - Fax:360-200-5278
Practice Address - Street 1:121 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1505
Practice Address - Country:US
Practice Address - Phone:360-794-5941
Practice Address - Fax:360-200-5278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031557Medicaid
WA2031557Medicaid