Provider Demographics
NPI:1659555860
Name:COLONIAL OPTICAL LLC
Entity Type:Organization
Organization Name:COLONIAL OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JUBIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-821-1820
Mailing Address - Street 1:12911 120TH AVE NE
Mailing Address - Street 2:SUITE C-80
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3027
Mailing Address - Country:US
Mailing Address - Phone:425-821-1820
Mailing Address - Fax:
Practice Address - Street 1:12911 120TH AVE NE
Practice Address - Street 2:SUITE C-80
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3027
Practice Address - Country:US
Practice Address - Phone:425-821-1820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003740152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty