Provider Demographics
NPI:1437331782
Name:RON COVERDALE OD PS
Entity Type:Organization
Organization Name:RON COVERDALE OD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RON
Authorized Official - Last Name:COVERDALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-485-3051
Mailing Address - Street 1:6830 NE BOTHELL WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-3546
Mailing Address - Country:US
Mailing Address - Phone:425-485-3051
Mailing Address - Fax:425-482-2441
Practice Address - Street 1:6830 NE BOTHELL WAY
Practice Address - Street 2:SUITE B
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-3546
Practice Address - Country:US
Practice Address - Phone:425-485-3051
Practice Address - Fax:425-482-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6313780001Medicare NSC