Provider Demographics
NPI:1134835176
Name:AEG WASHINGTON PROFESSIONAL PC
Entity type:Organization
Organization Name:AEG WASHINGTON PROFESSIONAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6206
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:12310 NE 8TH ST STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3185
Practice Address - Country:US
Practice Address - Phone:425-455-0001
Practice Address - Fax:314-741-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty