Provider Demographics
NPI:1922006758
Name:SPOKANE OPTICAL COMPANY LLC
Entity Type:Organization
Organization Name:SPOKANE OPTICAL COMPANY LLC
Other - Org Name:SPOKANE OPTICAL COMPANY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-456-0107
Mailing Address - Street 1:427 S BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2509
Mailing Address - Country:US
Mailing Address - Phone:509-456-0107
Mailing Address - Fax:509-747-2635
Practice Address - Street 1:427 S BERNARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2509
Practice Address - Country:US
Practice Address - Phone:509-456-0107
Practice Address - Fax:509-747-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602382529332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1922006758Medicaid
WA1922006758Medicaid
WA10803OtherLABOR AND INDUSTRIES
WA10803OtherLABOR AND INDUSTRIES