Provider Demographics
NPI:1972514917
Name:EYE CARE SPECIALISTS PS
Entity Type:Organization
Organization Name:EYE CARE SPECIALISTS PS
Other - Org Name:EYE CARE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-758-8811
Mailing Address - Street 1:500 PORT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1835
Mailing Address - Country:US
Mailing Address - Phone:509-758-8811
Mailing Address - Fax:509-751-1188
Practice Address - Street 1:500 PORT DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1835
Practice Address - Country:US
Practice Address - Phone:509-758-8811
Practice Address - Fax:509-751-1188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE CARE SPECIALISTS PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003976152W00000X
IDOPD-100067152W00000X
WA601269693156FC0801X
WAMD00014109207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7088859Medicaid
WA0123143OtherLABOR & IND
CN6339OtherRAILROAD MEDICARE
000010006387OtherREGENCE BLUE SHIELD
24509OtherGROUP HEALTH
ID85977OtherBLUE CROSS
ID805350600Medicaid
WA8927759OtherCRIME VICTIMS
ID805350600Medicaid
24509OtherGROUP HEALTH
WA0265530002Medicare NSC
WA7088859Medicaid