Provider Demographics
NPI:1467602524
Name:VISION PLUS INSIDE FERNDALE HAGGEN
Entity Type:Organization
Organization Name:VISION PLUS INSIDE FERNDALE HAGGEN
Other - Org Name:VISION PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DORON
Authorized Official - Last Name:AGINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-393-4000
Mailing Address - Street 1:1815 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9454
Mailing Address - Country:US
Mailing Address - Phone:360-393-4000
Mailing Address - Fax:360-393-4004
Practice Address - Street 1:1815 MAIN ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9454
Practice Address - Country:US
Practice Address - Phone:360-393-4000
Practice Address - Fax:360-393-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA152W0000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2035046Medicaid
WA2006335Medicaid
WAG8878872Medicare PIN
WA6253220001Medicare NSC
WA2035046Medicaid