Provider Demographics
NPI:1851537021
Name:VISION SOURCE WALLA WALLA
Entity Type:Organization
Organization Name:VISION SOURCE WALLA WALLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-529-9660
Mailing Address - Street 1:614 EAST ALDER ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2073
Mailing Address - Country:US
Mailing Address - Phone:509-529-9660
Mailing Address - Fax:509-529-4750
Practice Address - Street 1:614 EAST ALDER ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2073
Practice Address - Country:US
Practice Address - Phone:509-529-9660
Practice Address - Fax:509-529-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00001216152W00000X
WA00001578152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty