Provider Demographics
NPI:1609889039
Name:LIBERTY LAKE EYECARE CENTER PS
Entity Type:Organization
Organization Name:LIBERTY LAKE EYECARE CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-893-7574
Mailing Address - Street 1:2207 N MOLTER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7571
Mailing Address - Country:US
Mailing Address - Phone:509-893-7574
Mailing Address - Fax:509-893-3703
Practice Address - Street 1:22011 E COUNTRY VISTA DR STE 101
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-5242
Practice Address - Country:US
Practice Address - Phone:154-178-6332
Practice Address - Fax:509-893-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023067Medicaid
WAGAB40225Medicare PIN
WA1286900001Medicare NSC