Provider Demographics
NPI:1811023732
Name:LONGVIEW EYE & VISION
Entity Type:Organization
Organization Name:LONGVIEW EYE & VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:ORMAL
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-795-3223
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612-0399
Mailing Address - Country:US
Mailing Address - Phone:360-795-3223
Mailing Address - Fax:360-795-0738
Practice Address - Street 1:180 3RD STREET
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612
Practice Address - Country:US
Practice Address - Phone:360-795-3223
Practice Address - Fax:360-795-0738
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHLAMET EYE & VISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA410005544OtherRAIL ROAD MEDICARE
WA2027118Medicaid
WAG115121900Medicare PIN
WA0715790001Medicare NSC