Provider Demographics
NPI:1487860508
Name:NORTHEND OPTICAL INC.
Entity Type:Organization
Organization Name:NORTHEND OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC. TREAS.
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:253-759-2299
Mailing Address - Street 1:5917 N 26TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2359
Mailing Address - Country:US
Mailing Address - Phone:253-759-2299
Mailing Address - Fax:253-752-4930
Practice Address - Street 1:5917 N 26TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-2359
Practice Address - Country:US
Practice Address - Phone:253-759-2299
Practice Address - Fax:253-752-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2016269Medicaid
WA4985340001Medicare ID - Type Unspecified