Provider Demographics
NPI:1619225190
Name:RERECICH, SHANI ELIZA (OD)
Entity Type:Individual
Prefix:
First Name:SHANI
Middle Name:ELIZA
Last Name:RERECICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHANI
Other - Middle Name:ELIZA
Other - Last Name:ELWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5021 RIPLEY LANE N
Mailing Address - Street 2:#302
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1576
Mailing Address - Country:US
Mailing Address - Phone:425-273-4368
Mailing Address - Fax:
Practice Address - Street 1:1600 E. JEFFERSON ST
Practice Address - Street 2:STE #202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-1737
Practice Address - Country:US
Practice Address - Phone:425-320-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60291669152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist