Provider Demographics
NPI:1588798896
Name:SPENCER GARLICK OPTOMETRY, PLLC
Entity Type:Organization
Organization Name:SPENCER GARLICK OPTOMETRY, PLLC
Other - Org Name:FAMILY EYECARE ASSOCIATES, PS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-566-2020
Mailing Address - Street 1:6314 19TH ST W #1
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6223
Mailing Address - Country:US
Mailing Address - Phone:253-566-2020
Mailing Address - Fax:
Practice Address - Street 1:6314 19TH ST W #1
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6223
Practice Address - Country:US
Practice Address - Phone:253-566-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD1362152W00000X, 152WL0500X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2073005Medicaid
WA4263170002Medicare NSC
WA2073005Medicaid
WAT02716Medicare UPIN