Provider Demographics
NPI:1932308012
Name:COLUMBIA CREST EYE CARE INC PS
Entity Type:Organization
Organization Name:COLUMBIA CREST EYE CARE INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEPEW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-735-2020
Mailing Address - Street 1:7301 W DESCHUTES AVE STE B
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7799
Mailing Address - Country:US
Mailing Address - Phone:509-735-2020
Mailing Address - Fax:509-783-2135
Practice Address - Street 1:7301 W DESCHUTES AVE STE B
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7799
Practice Address - Country:US
Practice Address - Phone:509-735-2020
Practice Address - Fax:509-783-2135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBIA CREST EYE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2074706Medicaid
WA2029155Medicaid
WA2029155Medicaid
WA5178840001Medicare NSC