Provider Demographics
NPI:1447391669
Name:RAINIER VALLEY OPTOMETRIC, INC
Entity Type:Organization
Organization Name:RAINIER VALLEY OPTOMETRIC, INC
Other - Org Name:RAINIER VALLEY OPTOMETRIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAWZIDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TON-SUSILASATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-722-2218
Mailing Address - Street 1:7101 MARTIN LUTHER KING JR WAY S
Mailing Address - Street 2:#209
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3594
Mailing Address - Country:US
Mailing Address - Phone:206-722-2218
Mailing Address - Fax:206-722-2211
Practice Address - Street 1:7101 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:#209
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3594
Practice Address - Country:US
Practice Address - Phone:206-722-2218
Practice Address - Fax:206-722-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029262Medicaid
WA2029262Medicaid