Provider Demographics
NPI:1578731170
Name:VILLAGE EYE CARE, LLC
Entity Type:Organization
Organization Name:VILLAGE EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-939-0604
Mailing Address - Street 1:9606 271ST ST NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-8096
Mailing Address - Country:US
Mailing Address - Phone:360-939-0604
Mailing Address - Fax:
Practice Address - Street 1:9606 271ST ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-8096
Practice Address - Country:US
Practice Address - Phone:360-939-0604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034734Medicaid
G8877176Medicare PIN
WA2034734Medicaid