Provider Demographics
NPI:1023175163
Name:VISION SOURCE OF WENATCHEE, PS
Entity type:Organization
Organization Name:VISION SOURCE OF WENATCHEE, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DONAGHEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-662-9671
Mailing Address - Street 1:1190 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1825
Mailing Address - Country:US
Mailing Address - Phone:509-662-9671
Mailing Address - Fax:509-662-9672
Practice Address - Street 1:1190 5TH ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1825
Practice Address - Country:US
Practice Address - Phone:509-662-9671
Practice Address - Fax:509-662-9672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1494152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030914Medicaid
WA5665620001Medicare NSC
WA2030914Medicaid