Provider Demographics
NPI:1831302223
Name:WILLOWS OPTICAL SHOP INC.
Entity Type:Organization
Organization Name:WILLOWS OPTICAL SHOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:JOBE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:253-848-2338
Mailing Address - Street 1:13909 MERIDIAN E
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-9180
Mailing Address - Country:US
Mailing Address - Phone:253-848-2338
Mailing Address - Fax:253-840-5543
Practice Address - Street 1:13909 MERIDIAN E
Practice Address - Street 2:SUITE A-4
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-9180
Practice Address - Country:US
Practice Address - Phone:253-848-2338
Practice Address - Fax:253-840-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty