Provider Demographics
NPI:1598941890
Name:PUYALLUP VISION CENTER PS
Entity Type:Organization
Organization Name:PUYALLUP VISION CENTER PS
Other - Org Name:PUYALLUP VISION SOURCE
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LINTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:253-845-8215
Mailing Address - Street 1:113 PIONEER WEST
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371
Mailing Address - Country:US
Mailing Address - Phone:253-845-8215
Mailing Address - Fax:
Practice Address - Street 1:113 PIONEER WEST
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371
Practice Address - Country:US
Practice Address - Phone:253-845-8215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB12527Medicare PIN
WA0646370001Medicare NSC