Provider Demographics
NPI:1558475558
Name:MAPLE VALLEY VISION CLINIC PLLC
Entity Type:Organization
Organization Name:MAPLE VALLEY VISION CLINIC PLLC
Other - Org Name:MAPLE VALLEY VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNION
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-432-1206
Mailing Address - Street 1:23714 222ND PL SE STE B
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5800
Mailing Address - Country:US
Mailing Address - Phone:425-432-1206
Mailing Address - Fax:425-413-4465
Practice Address - Street 1:23714 222ND PL SE STE B
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-432-1206
Practice Address - Fax:425-413-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA1115TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032050Medicaid
WA2032050Medicaid
WA8860947Medicare PIN