Provider Demographics
NPI:1497810071
Name:WHIDBEY VISION CARE INC PS
Entity Type:Organization
Organization Name:WHIDBEY VISION CARE INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-675-2235
Mailing Address - Street 1:380 SE BARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-3266
Mailing Address - Country:US
Mailing Address - Phone:360-675-2235
Mailing Address - Fax:360-679-2150
Practice Address - Street 1:380 SE BARRINGTON DR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3266
Practice Address - Country:US
Practice Address - Phone:360-675-2235
Practice Address - Fax:360-679-2150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003150152W00000X
WAOD00003901152W00000X
WAOD00003987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006765Medicaid
WA2030591Medicaid
WA2031367Medicaid
WAGAB16481Medicare PIN
WA0728290001Medicare NSC
WAV10863Medicare UPIN
WA2030591Medicaid