Provider Demographics
NPI:1558451369
Name:EDMONDS EYECARE ASSOCIATES INC PS
Entity Type:Organization
Organization Name:EDMONDS EYECARE ASSOCIATES INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-774-2020
Mailing Address - Street 1:7315 212TH ST SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7610
Mailing Address - Country:US
Mailing Address - Phone:425-774-2020
Mailing Address - Fax:425-670-8932
Practice Address - Street 1:7315 212TH ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-774-2020
Practice Address - Fax:425-670-8932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1736TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========OtherTAX ID #
WA001263000Medicare ID - Type UnspecifiedMEDICARE GROUP #
0291040001Medicare NSC