Provider Demographics
NPI:1477612463
Name:KITSAP EYECARE CENTERS INC PS
Entity Type:Organization
Organization Name:KITSAP EYECARE CENTERS INC PS
Other - Org Name:POULSBO EYECARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-779-2336
Mailing Address - Street 1:19220 8TH AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8773
Mailing Address - Country:US
Mailing Address - Phone:360-779-2336
Mailing Address - Fax:360-779-7628
Practice Address - Street 1:19220 8TH AVE NE
Practice Address - Street 2:SUITE A
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8773
Practice Address - Country:US
Practice Address - Phone:360-779-2336
Practice Address - Fax:360-779-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601379904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty