Provider Demographics
NPI:1841232121
Name:ENUMCLAW FAMILY OPTOMETRY CLINIC PS
Entity Type:Organization
Organization Name:ENUMCLAW FAMILY OPTOMETRY CLINIC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-825-3000
Mailing Address - Street 1:2726 GRIFFIN AVE
Mailing Address - Street 2:STE B
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2362
Mailing Address - Country:US
Mailing Address - Phone:360-825-3000
Mailing Address - Fax:360-825-8408
Practice Address - Street 1:2726 GRIFFIN AVE
Practice Address - Street 2:STE B
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2362
Practice Address - Country:US
Practice Address - Phone:360-825-3000
Practice Address - Fax:360-825-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASH2147OtherREGENCE
WA1020256Medicaid
WA2016699Medicaid
T60932Medicare UPIN
WA2016699Medicaid
WA0309740001Medicare NSC