Provider Demographics
NPI:1851664346
Name:WILLIAM J WICKLINE, O.D., INC.
Entity Type:Organization
Organization Name:WILLIAM J WICKLINE, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WICKLINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-681-3937
Mailing Address - Street 1:680 W WASHINGTON ST STE E102
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3264
Mailing Address - Country:US
Mailing Address - Phone:360-681-3937
Mailing Address - Fax:360-681-2744
Practice Address - Street 1:680 W WASHINGTON ST STE E102
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3264
Practice Address - Country:US
Practice Address - Phone:360-681-3937
Practice Address - Fax:360-681-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD0001525TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2080703Medicaid
WA2080703Medicaid
WAG000500173Medicare PIN