Provider Demographics
NPI:1629297171
Name:FAMILY EYE CARE PS
Entity Type:Organization
Organization Name:FAMILY EYE CARE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-783-0667
Mailing Address - Street 1:7903 W GRANDRIDGE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7827
Mailing Address - Country:US
Mailing Address - Phone:506-783-0667
Mailing Address - Fax:509-735-7981
Practice Address - Street 1:7903 W GRANDRIDGE BLVD STE A
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7827
Practice Address - Country:US
Practice Address - Phone:506-783-0667
Practice Address - Fax:509-735-7981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1091TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020410Medicaid
WA0469740001Medicare NSC