Provider Demographics
NPI:1578651048
Name:MERRELL, MELVIN CLYDE (LDO/ABOM)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:CLYDE
Last Name:MERRELL
Suffix:
Gender:M
Credentials:LDO/ABOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-1005
Mailing Address - Country:US
Mailing Address - Phone:360-274-5889
Mailing Address - Fax:
Practice Address - Street 1:1230 SEVENTH AVE.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-636-6238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00000643156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician