Provider Demographics
NPI:1518560184
Name:MAX VISION PLLC
Entity Type:Organization
Organization Name:MAX VISION PLLC
Other - Org Name:EYE 5 OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KORY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTELHO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-575-4396
Mailing Address - Street 1:415 N G ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-2328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 STRANDER BLVD STE 202
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2959
Practice Address - Country:US
Practice Address - Phone:206-575-4396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1407302003Medicaid