Provider Demographics
NPI:1972851020
Name:SPOKANE OPTICAL COMPANY LLC
Entity Type:Organization
Organization Name:SPOKANE OPTICAL COMPANY LLC
Other - Org Name:SPOKANE OPTICAL COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-456-0107
Mailing Address - Street 1:16201 E INDIANA AVE
Mailing Address - Street 2:5000
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2830
Mailing Address - Country:US
Mailing Address - Phone:509-924-7271
Mailing Address - Fax:509-928-7802
Practice Address - Street 1:16201 E INDIANA AVE
Practice Address - Street 2:5000
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2830
Practice Address - Country:US
Practice Address - Phone:509-924-7271
Practice Address - Fax:509-928-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-21
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602617024332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0292200001Medicare NSC