Provider Demographics
NPI:1609948926
Name:STUECKLE, LOREN G (OD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:G
Last Name:STUECKLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-0147
Mailing Address - Country:US
Mailing Address - Phone:509-952-4574
Mailing Address - Fax:509-697-3223
Practice Address - Street 1:1321 N COLUMBIA CENTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2184
Practice Address - Country:US
Practice Address - Phone:509-783-2555
Practice Address - Fax:509-783-0838
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD 1306152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
602011840OtherUBI
602011840OtherUBI
602011840OtherUBI
WAGAB14862Medicare PIN
T02090Medicare UPIN
WAG8867989Medicare PIN