Provider Demographics
NPI:1588822548
Name:MEDNIC, PC
Entity Type:Organization
Organization Name:MEDNIC, PC
Other - Org Name:CAMAS VISION CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEDESKI-NICACIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-694-6541
Mailing Address - Street 1:912 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3136
Mailing Address - Country:US
Mailing Address - Phone:360-694-6541
Mailing Address - Fax:360-696-2578
Practice Address - Street 1:225 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2125
Practice Address - Country:US
Practice Address - Phone:360-834-2063
Practice Address - Fax:360-834-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1808TX152W00000X
WA1999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023141Medicaid
WA2023141Medicaid
WAGAB13045Medicare PIN
WAU29339Medicare UPIN
WA4148630001Medicare NSC