Provider Demographics
NPI:1598855876
Name:NORTHSIDE VISION CENTER, P.S.
Entity Type:Organization
Organization Name:NORTHSIDE VISION CENTER, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FAIRBORN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-326-2772
Mailing Address - Street 1:601 W FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6427
Mailing Address - Country:US
Mailing Address - Phone:509-326-2772
Mailing Address - Fax:509-327-1405
Practice Address - Street 1:601 W FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6427
Practice Address - Country:US
Practice Address - Phone:509-326-2772
Practice Address - Fax:509-327-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3995TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE3597OtherRAILROAD MEDICARE PIN
WA2031219Medicaid
WA5493150001OtherDME#
WA2031219Medicaid