Provider Demographics
NPI:1649403122
Name:KORNMESSER OPTOMETRY CLINIC INC PS.
Entity Type:Organization
Organization Name:KORNMESSER OPTOMETRY CLINIC INC PS.
Other - Org Name:DR. JAMES H. GRIMES
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MERRIEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-426-5578
Mailing Address - Street 1:422 W BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-1735
Mailing Address - Country:US
Mailing Address - Phone:360-426-5578
Mailing Address - Fax:360-462-5580
Practice Address - Street 1:422 W BIRCH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-1735
Practice Address - Country:US
Practice Address - Phone:360-426-5578
Practice Address - Fax:360-462-5580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA09-0000870152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2467009Medicaid
WAT02167Medicare UPIN
WA000200158Medicare PIN