Provider Demographics
NPI:1669663936
Name:VANCUVER ENT AND ENT OPF NW, PLLC
Entity Type:Organization
Organization Name:VANCUVER ENT AND ENT OPF NW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:EBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-636-4469
Mailing Address - Street 1:1801 1ST AVE
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3270
Mailing Address - Country:US
Mailing Address - Phone:360-636-4469
Mailing Address - Fax:
Practice Address - Street 1:1801 1ST AVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3270
Practice Address - Country:US
Practice Address - Phone:360-636-4469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001333332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9059015Medicaid