Provider Demographics
NPI:1659587988
Name:PORT ORCHARD EYE ASSOCIATES, INC. PS
Entity Type:Organization
Organization Name:PORT ORCHARD EYE ASSOCIATES, INC. PS
Other - Org Name:PACIFIC EYECARE OF PORT ORCHARDEYEDESIGNS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-895-2020
Mailing Address - Street 1:1135 BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3125
Mailing Address - Country:US
Mailing Address - Phone:360-895-2020
Mailing Address - Fax:360-874-0048
Practice Address - Street 1:1135 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3125
Practice Address - Country:US
Practice Address - Phone:360-895-2020
Practice Address - Fax:360-874-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5989750001Medicare NSC