Provider Demographics
NPI:1609554229
Name:VISTA OPTOMETRIC
Entity Type:Organization
Organization Name:VISTA OPTOMETRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-902-9758
Mailing Address - Street 1:2481 EASY ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-5814
Mailing Address - Country:US
Mailing Address - Phone:760-690-2975
Mailing Address - Fax:
Practice Address - Street 1:2000 N WENATCHEE AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1056
Practice Address - Country:US
Practice Address - Phone:509-888-3370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISTA OPTOMETRIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty