Provider Demographics
NPI:1871683144
Name:RENTON VISION CENTER INC PS
Entity Type:Organization
Organization Name:RENTON VISION CENTER INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-841-1575
Mailing Address - Street 1:PO BOX 23896
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-0896
Mailing Address - Country:US
Mailing Address - Phone:253-735-6163
Mailing Address - Fax:253-840-5543
Practice Address - Street 1:13909 MERIDIAN E
Practice Address - Street 2:A3
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-9180
Practice Address - Country:US
Practice Address - Phone:253-841-1575
Practice Address - Fax:253-840-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1004TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007664Medicaid
000104452Medicare PIN