Provider Demographics
NPI:1710043161
Name:LAKE FOREST VISION
Entity Type:Organization
Organization Name:LAKE FOREST VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF OPTOMETRY
Authorized Official - Phone:206-363-9292
Mailing Address - Street 1:17171 BOTHELL WAY NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5534
Mailing Address - Country:US
Mailing Address - Phone:206-363-9292
Mailing Address - Fax:206-362-4620
Practice Address - Street 1:17171 BOTHELL WAY NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-5534
Practice Address - Country:US
Practice Address - Phone:206-363-9292
Practice Address - Fax:206-362-4620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001793332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT-02007Medicare UPIN